| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,447 |
2,442 |
$127K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
797 |
524 |
$98K |
| D0120 |
Periodic oral evaluation - established patient |
3,025 |
3,020 |
$80K |
| D2740 |
Crown - porcelain/ceramic |
102 |
61 |
$72K |
| D1120 |
Prophylaxis - child |
1,576 |
1,576 |
$58K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
294 |
191 |
$44K |
| D0274 |
Bitewings - four radiographic images |
1,075 |
1,075 |
$36K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,150 |
2,148 |
$34K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
817 |
817 |
$33K |
| D0140 |
Limited oral evaluation - problem focused |
1,158 |
982 |
$33K |
| D0220 |
Intraoral - periapical first radiographic image |
1,646 |
1,621 |
$27K |
| D0210 |
Intraoral - complete series of radiographic images |
255 |
255 |
$19K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,271 |
1,058 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
70 |
55 |
$7K |
| D0272 |
Bitewings - two radiographic images |
138 |
138 |
$3K |
| D1999 |
|
2,070 |
1,805 |
$0.00 |