| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,193 |
3,190 |
$117K |
| D0120 |
Periodic oral evaluation - established patient |
3,605 |
3,600 |
$72K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
770 |
483 |
$51K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,552 |
2,535 |
$38K |
| D0220 |
Intraoral - periapical first radiographic image |
2,786 |
2,755 |
$28K |
| D0210 |
Intraoral - complete series of radiographic images |
1,967 |
1,956 |
$27K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
245 |
159 |
$16K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
19 |
13 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
387 |
387 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
291 |
291 |
$3K |
| D0274 |
Bitewings - four radiographic images |
90 |
89 |
$2K |