| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,282 |
2,281 |
$103K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
974 |
592 |
$68K |
| D0120 |
Periodic oral evaluation - established patient |
2,624 |
2,624 |
$66K |
| D1120 |
Prophylaxis - child |
887 |
887 |
$40K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,219 |
1,219 |
$30K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
502 |
312 |
$28K |
| D0274 |
Bitewings - four radiographic images |
2,252 |
2,252 |
$27K |
| D0140 |
Limited oral evaluation - problem focused |
408 |
401 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
3,115 |
3,081 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
550 |
550 |
$14K |
| D0210 |
Intraoral - complete series of radiographic images |
255 |
255 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,800 |
2,794 |
$11K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
111 |
76 |
$9K |
| D2740 |
Crown - porcelain/ceramic |
17 |
15 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
38 |
26 |
$2K |