| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
5,667 |
5,667 |
$232K |
| D0120 |
Periodic oral evaluation - established patient |
6,600 |
6,600 |
$143K |
| D0274 |
Bitewings - four radiographic images |
6,153 |
6,153 |
$133K |
| D2750 |
|
276 |
182 |
$106K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,185 |
4,183 |
$39K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
448 |
338 |
$29K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,783 |
1,783 |
$22K |
| D1120 |
Prophylaxis - child |
402 |
402 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
254 |
205 |
$13K |
| D2952 |
|
54 |
43 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
155 |
155 |
$6K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
13 |
12 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
39 |
26 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
73 |
73 |
$611.76 |