| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,736 |
1,617 |
$79K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
306 |
183 |
$37K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
965 |
833 |
$27K |
| D0120 |
Periodic oral evaluation - established patient |
1,061 |
1,007 |
$23K |
| D2740 |
Crown - porcelain/ceramic |
31 |
29 |
$20K |
| D0274 |
Bitewings - four radiographic images |
509 |
471 |
$15K |
| D0140 |
Limited oral evaluation - problem focused |
456 |
414 |
$13K |
| D0210 |
Intraoral - complete series of radiographic images |
244 |
208 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
715 |
646 |
$11K |
| D1206 |
Topical application of fluoride varnish |
519 |
496 |
$10K |
| D1120 |
Prophylaxis - child |
138 |
132 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
80 |
44 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
15 |
12 |
$3K |
| D2331 |
|
23 |
14 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
75 |
71 |
$660.85 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$318.72 |
| D9630 |
|
15 |
14 |
$177.40 |