| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,149 |
2,143 |
$74K |
| D0120 |
Periodic oral evaluation - established patient |
2,792 |
2,784 |
$54K |
| D0274 |
Bitewings - four radiographic images |
1,894 |
1,893 |
$36K |
| D0220 |
Intraoral - periapical first radiographic image |
2,413 |
2,396 |
$22K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
314 |
252 |
$17K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,288 |
2,264 |
$17K |
| D0210 |
Intraoral - complete series of radiographic images |
547 |
544 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
54 |
50 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
308 |
308 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
43 |
43 |
$3K |
| D1120 |
Prophylaxis - child |
115 |
114 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
45 |
38 |
$2K |
| D2160 |
|
14 |
13 |
$1K |
| D2140 |
|
14 |
12 |
$511.00 |