| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
815 |
815 |
$41K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
247 |
144 |
$31K |
| D0120 |
Periodic oral evaluation - established patient |
1,143 |
1,143 |
$30K |
| D1206 |
Topical application of fluoride varnish |
794 |
793 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
1,100 |
1,082 |
$17K |
| D1120 |
Prophylaxis - child |
450 |
450 |
$17K |
| D0140 |
Limited oral evaluation - problem focused |
372 |
369 |
$15K |
| D2740 |
Crown - porcelain/ceramic |
20 |
13 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
322 |
321 |
$13K |
| D0274 |
Bitewings - four radiographic images |
253 |
253 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
504 |
465 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
41 |
25 |
$4K |
| D2950 |
|
20 |
12 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
25 |
25 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
18 |
12 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
13 |
$325.00 |