| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,275 |
1,151 |
$65K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
728 |
321 |
$41K |
| D0274 |
Bitewings - four radiographic images |
1,029 |
931 |
$35K |
| D0120 |
Periodic oral evaluation - established patient |
1,252 |
1,131 |
$28K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
367 |
336 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
194 |
124 |
$15K |
| D1120 |
Prophylaxis - child |
305 |
285 |
$15K |
| D0210 |
Intraoral - complete series of radiographic images |
213 |
196 |
$14K |
| D0140 |
Limited oral evaluation - problem focused |
372 |
336 |
$13K |
| D2740 |
Crown - porcelain/ceramic |
14 |
12 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
321 |
299 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
251 |
224 |
$4K |
| D1206 |
Topical application of fluoride varnish |
50 |
50 |
$1K |