| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,660 |
2,643 |
$117K |
| D0120 |
Periodic oral evaluation - established patient |
3,698 |
3,677 |
$87K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
573 |
346 |
$74K |
| D4910 |
|
827 |
818 |
$55K |
| D7140 |
Extraction, erupted tooth or exposed root |
470 |
88 |
$42K |
| D0210 |
Intraoral - complete series of radiographic images |
575 |
571 |
$40K |
| D0274 |
Bitewings - four radiographic images |
1,346 |
1,344 |
$40K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,036 |
1,032 |
$40K |
| D0220 |
Intraoral - periapical first radiographic image |
2,319 |
2,294 |
$29K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,781 |
1,773 |
$23K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
197 |
137 |
$20K |
| D1206 |
Topical application of fluoride varnish |
1,029 |
1,022 |
$20K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
81 |
59 |
$13K |
| D4342 |
|
73 |
27 |
$6K |
| D1120 |
Prophylaxis - child |
197 |
197 |
$6K |
| D2740 |
Crown - porcelain/ceramic |
13 |
13 |
$5K |