| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,230 |
2,217 |
$82K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,395 |
270 |
$67K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,152 |
351 |
$61K |
| D0330 |
Panoramic radiographic image |
973 |
973 |
$32K |
| D0120 |
Periodic oral evaluation - established patient |
1,327 |
1,316 |
$31K |
| D2330 |
|
646 |
120 |
$29K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
966 |
966 |
$22K |
| D2740 |
Crown - porcelain/ceramic |
91 |
51 |
$20K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
575 |
210 |
$20K |
| D0274 |
Bitewings - four radiographic images |
1,387 |
1,382 |
$15K |
| D0140 |
Limited oral evaluation - problem focused |
96 |
94 |
$3K |
| D4210 |
|
76 |
18 |
$3K |
| D2335 |
|
44 |
12 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
699 |
684 |
$3K |
| D4341 |
|
65 |
14 |
$2K |
| D2952 |
|
32 |
13 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
676 |
663 |
$1K |
| D2332 |
|
21 |
12 |
$840.00 |
| D1120 |
Prophylaxis - child |
13 |
13 |
$422.50 |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$234.00 |
| D0603 |
|
12 |
12 |
$120.00 |