| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,828 |
1,828 |
$67K |
| D0120 |
Periodic oral evaluation - established patient |
2,484 |
2,483 |
$49K |
| D0210 |
Intraoral - complete series of radiographic images |
1,714 |
1,714 |
$44K |
| D0220 |
Intraoral - periapical first radiographic image |
1,179 |
1,176 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
689 |
689 |
$9K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
20 |
13 |
$7K |
| D0274 |
Bitewings - four radiographic images |
208 |
208 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
100 |
80 |
$4K |
| D2954 |
|
18 |
13 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
88 |
88 |
$931.70 |
| D2140 |
|
27 |
16 |
$833.70 |
| D1120 |
Prophylaxis - child |
24 |
24 |
$744.23 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
20 |
12 |
$684.96 |