| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,182 |
2,179 |
$91K |
| D0120 |
Periodic oral evaluation - established patient |
2,180 |
2,178 |
$53K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
439 |
364 |
$41K |
| D0140 |
Limited oral evaluation - problem focused |
674 |
662 |
$22K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
208 |
183 |
$20K |
| D1208 |
Topical application of fluoride, excluding varnish |
780 |
780 |
$20K |
| D0274 |
Bitewings - four radiographic images |
660 |
659 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
1,516 |
1,406 |
$17K |
| D1120 |
Prophylaxis - child |
399 |
399 |
$16K |
| D2740 |
Crown - porcelain/ceramic |
20 |
13 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
188 |
188 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
331 |
191 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
15 |
15 |
$1K |
| D2394 |
|
14 |
12 |
$1K |
| D1999 |
|
111 |
94 |
$0.00 |