| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,590 |
1,590 |
$72K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
689 |
469 |
$48K |
| D1206 |
Topical application of fluoride varnish |
1,417 |
1,415 |
$44K |
| D0120 |
Periodic oral evaluation - established patient |
1,747 |
1,747 |
$44K |
| D0274 |
Bitewings - four radiographic images |
1,306 |
1,305 |
$16K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
243 |
179 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
1,799 |
1,795 |
$9K |
| D1120 |
Prophylaxis - child |
200 |
200 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,495 |
1,493 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
178 |
178 |
$8K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
14 |
12 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
104 |
103 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
121 |
121 |
$3K |
| D0603 |
|
270 |
270 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
16 |
16 |
$400.00 |