| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,787 |
2,787 |
$115K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
906 |
775 |
$59K |
| D0120 |
Periodic oral evaluation - established patient |
2,429 |
2,429 |
$50K |
| D0274 |
Bitewings - four radiographic images |
1,217 |
1,217 |
$25K |
| D0220 |
Intraoral - periapical first radiographic image |
2,013 |
2,013 |
$20K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
30 |
28 |
$13K |
| D9310 |
|
195 |
195 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
458 |
458 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,524 |
1,524 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
108 |
101 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
389 |
389 |
$4K |
| D1120 |
Prophylaxis - child |
123 |
123 |
$4K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
29 |
26 |
$2K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
27 |
26 |
$2K |