| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,235 |
1,234 |
$66K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
518 |
322 |
$66K |
| D0120 |
Periodic oral evaluation - established patient |
2,132 |
2,130 |
$60K |
| D2740 |
Crown - porcelain/ceramic |
62 |
43 |
$49K |
| D1120 |
Prophylaxis - child |
962 |
962 |
$40K |
| D0274 |
Bitewings - four radiographic images |
969 |
967 |
$34K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
361 |
186 |
$34K |
| D0220 |
Intraoral - periapical first radiographic image |
1,373 |
1,326 |
$23K |
| D1208 |
Topical application of fluoride, excluding varnish |
784 |
784 |
$19K |
| D0140 |
Limited oral evaluation - problem focused |
312 |
290 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,335 |
1,195 |
$13K |
| D1206 |
Topical application of fluoride varnish |
151 |
151 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
100 |
99 |
$4K |
| D2950 |
|
21 |
14 |
$4K |