| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,854 |
2,841 |
$101K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,970 |
1,062 |
$84K |
| D0120 |
Periodic oral evaluation - established patient |
3,291 |
3,272 |
$66K |
| D0210 |
Intraoral - complete series of radiographic images |
1,459 |
1,446 |
$50K |
| D0274 |
Bitewings - four radiographic images |
1,982 |
1,975 |
$38K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
464 |
365 |
$24K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
474 |
333 |
$23K |
| D0220 |
Intraoral - periapical first radiographic image |
2,334 |
2,318 |
$22K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,395 |
2,371 |
$18K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,359 |
1,352 |
$14K |
| D1120 |
Prophylaxis - child |
359 |
359 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
280 |
279 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
110 |
66 |
$5K |
| D9110 |
|
17 |
13 |
$181.98 |