| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
832 |
823 |
$74K |
| D0120 |
Periodic oral evaluation - established patient |
877 |
870 |
$61K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
684 |
684 |
$45K |
| D1206 |
Topical application of fluoride varnish |
1,526 |
1,515 |
$24K |
| D0210 |
Intraoral - complete series of radiographic images |
492 |
492 |
$23K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,168 |
936 |
$21K |
| D4910 |
|
229 |
229 |
$18K |
| D0274 |
Bitewings - four radiographic images |
785 |
777 |
$17K |
| D9430 |
|
494 |
437 |
$16K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
235 |
124 |
$16K |
| D1120 |
Prophylaxis - child |
298 |
297 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
226 |
118 |
$12K |
| D2740 |
Crown - porcelain/ceramic |
13 |
12 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
407 |
377 |
$5K |
| D0350 |
|
222 |
73 |
$2K |