| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,931 |
1,819 |
$100K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
929 |
472 |
$75K |
| D0274 |
Bitewings - four radiographic images |
1,292 |
1,199 |
$45K |
| D0120 |
Periodic oral evaluation - established patient |
1,658 |
1,555 |
$38K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
736 |
721 |
$32K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
503 |
278 |
$32K |
| D0210 |
Intraoral - complete series of radiographic images |
429 |
420 |
$31K |
| D0220 |
Intraoral - periapical first radiographic image |
1,754 |
1,627 |
$27K |
| D2740 |
Crown - porcelain/ceramic |
29 |
25 |
$21K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,561 |
1,360 |
$20K |
| D1120 |
Prophylaxis - child |
336 |
326 |
$18K |
| D1208 |
Topical application of fluoride, excluding varnish |
494 |
482 |
$15K |
| D0140 |
Limited oral evaluation - problem focused |
117 |
117 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
50 |
29 |
$4K |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$336.00 |