| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,844 |
1,822 |
$118K |
| D1206 |
Topical application of fluoride varnish |
2,554 |
2,529 |
$64K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,153 |
1,134 |
$64K |
| D0330 |
Panoramic radiographic image |
1,263 |
1,242 |
$57K |
| D0120 |
Periodic oral evaluation - established patient |
1,451 |
1,444 |
$44K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
286 |
140 |
$27K |
| D7140 |
Extraction, erupted tooth or exposed root |
170 |
79 |
$21K |
| D2740 |
Crown - porcelain/ceramic |
15 |
13 |
$6K |
| D1120 |
Prophylaxis - child |
89 |
89 |
$4K |
| D2330 |
|
30 |
14 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
13 |
12 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
24 |
24 |
$260.04 |