| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,451 |
3,450 |
$152K |
| D0120 |
Periodic oral evaluation - established patient |
5,533 |
5,531 |
$124K |
| D0274 |
Bitewings - four radiographic images |
3,102 |
3,102 |
$70K |
| D1120 |
Prophylaxis - child |
1,487 |
1,487 |
$49K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
565 |
500 |
$33K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,342 |
2,342 |
$29K |
| D0210 |
Intraoral - complete series of radiographic images |
631 |
630 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
1,426 |
1,420 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
482 |
482 |
$5K |
| D0272 |
Bitewings - two radiographic images |
184 |
184 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
34 |
31 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
13 |
12 |
$443.84 |