| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,987 |
1,984 |
$92K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,290 |
888 |
$85K |
| D0120 |
Periodic oral evaluation - established patient |
3,075 |
3,070 |
$80K |
| D1120 |
Prophylaxis - child |
1,631 |
1,629 |
$76K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
865 |
601 |
$48K |
| D0140 |
Limited oral evaluation - problem focused |
771 |
747 |
$32K |
| D1206 |
Topical application of fluoride varnish |
830 |
830 |
$27K |
| D1208 |
Topical application of fluoride, excluding varnish |
762 |
760 |
$20K |
| D0274 |
Bitewings - four radiographic images |
1,574 |
1,571 |
$19K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
213 |
191 |
$18K |
| D2740 |
Crown - porcelain/ceramic |
29 |
25 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
501 |
501 |
$13K |
| D7140 |
Extraction, erupted tooth or exposed root |
153 |
130 |
$8K |
| D0272 |
Bitewings - two radiographic images |
559 |
555 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
742 |
739 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
376 |
375 |
$3K |
| D2331 |
|
38 |
28 |
$3K |
| D0270 |
|
323 |
322 |
$2K |
| D2332 |
|
22 |
16 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
29 |
29 |
$1K |