| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,874 |
1,856 |
$78K |
| D0140 |
Limited oral evaluation - problem focused |
1,271 |
1,240 |
$42K |
| D0120 |
Periodic oral evaluation - established patient |
1,793 |
1,776 |
$41K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
922 |
910 |
$35K |
| D0220 |
Intraoral - periapical first radiographic image |
2,335 |
2,278 |
$29K |
| D0274 |
Bitewings - four radiographic images |
758 |
753 |
$22K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,334 |
1,301 |
$17K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
75 |
54 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
132 |
131 |
$10K |
| D7140 |
Extraction, erupted tooth or exposed root |
101 |
37 |
$10K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
13 |
12 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
16 |
12 |
$2K |
| D1120 |
Prophylaxis - child |
13 |
13 |
$390.78 |