| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,289 |
3,288 |
$167K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,491 |
948 |
$125K |
| D0120 |
Periodic oral evaluation - established patient |
4,460 |
4,459 |
$117K |
| D0210 |
Intraoral - complete series of radiographic images |
1,686 |
1,684 |
$80K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
58 |
52 |
$28K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
514 |
358 |
$28K |
| D0274 |
Bitewings - four radiographic images |
758 |
758 |
$20K |
| D7140 |
Extraction, erupted tooth or exposed root |
252 |
131 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
280 |
280 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
490 |
490 |
$7K |
| D4341 |
|
111 |
55 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
51 |
39 |
$6K |
| D1120 |
Prophylaxis - child |
127 |
127 |
$5K |
| D1351 |
Sealant - per tooth |
79 |
25 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
256 |
253 |
$3K |
| D2954 |
|
12 |
12 |
$2K |
| D4910 |
|
29 |
29 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
56 |
56 |
$1K |