| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,671 |
1,646 |
$104K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
767 |
428 |
$102K |
| D0120 |
Periodic oral evaluation - established patient |
2,230 |
2,200 |
$67K |
| D1120 |
Prophylaxis - child |
1,398 |
1,380 |
$62K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,046 |
1,033 |
$57K |
| D1206 |
Topical application of fluoride varnish |
2,165 |
2,133 |
$54K |
| D0210 |
Intraoral - complete series of radiographic images |
695 |
686 |
$39K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
229 |
153 |
$24K |
| D0140 |
Limited oral evaluation - problem focused |
513 |
498 |
$24K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
107 |
64 |
$18K |
| D0330 |
Panoramic radiographic image |
403 |
398 |
$18K |
| D0274 |
Bitewings - four radiographic images |
556 |
548 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
525 |
521 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
567 |
546 |
$6K |
| D2740 |
Crown - porcelain/ceramic |
16 |
13 |
$5K |
| D1351 |
Sealant - per tooth |
106 |
15 |
$4K |
| D0272 |
Bitewings - two radiographic images |
189 |
186 |
$3K |
| D0270 |
|
202 |
199 |
$2K |
| D1330 |
|
101 |
101 |
$727.20 |