| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,933 |
3,932 |
$146K |
| D0120 |
Periodic oral evaluation - established patient |
4,708 |
4,707 |
$95K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,973 |
3,970 |
$49K |
| D0272 |
Bitewings - two radiographic images |
3,598 |
3,598 |
$42K |
| D0210 |
Intraoral - complete series of radiographic images |
548 |
548 |
$12K |
| D1120 |
Prophylaxis - child |
275 |
275 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
910 |
909 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
642 |
642 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
185 |
96 |
$7K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
69 |
48 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
86 |
71 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
16 |
13 |
$1K |
| D0274 |
Bitewings - four radiographic images |
29 |
29 |
$602.46 |