| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,406 |
2,406 |
$100K |
| D0120 |
Periodic oral evaluation - established patient |
4,309 |
4,309 |
$97K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,383 |
999 |
$85K |
| D0274 |
Bitewings - four radiographic images |
3,700 |
3,700 |
$82K |
| D1120 |
Prophylaxis - child |
1,570 |
1,570 |
$59K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
752 |
604 |
$33K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,581 |
2,581 |
$33K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,006 |
4,004 |
$25K |
| D0220 |
Intraoral - periapical first radiographic image |
2,685 |
2,685 |
$24K |
| D7140 |
Extraction, erupted tooth or exposed root |
58 |
42 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
60 |
60 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
127 |
127 |
$1K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
18 |
16 |
$1K |