| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,920 |
1,902 |
$124K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
869 |
468 |
$116K |
| D0120 |
Periodic oral evaluation - established patient |
2,233 |
2,208 |
$69K |
| D1206 |
Topical application of fluoride varnish |
2,694 |
2,662 |
$69K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
630 |
309 |
$66K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
844 |
819 |
$46K |
| D4341 |
|
507 |
202 |
$40K |
| D0330 |
Panoramic radiographic image |
897 |
873 |
$40K |
| D0274 |
Bitewings - four radiographic images |
1,494 |
1,462 |
$35K |
| D1120 |
Prophylaxis - child |
667 |
655 |
$31K |
| D0140 |
Limited oral evaluation - problem focused |
554 |
539 |
$25K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
140 |
97 |
$24K |
| D2740 |
Crown - porcelain/ceramic |
30 |
26 |
$11K |
| D1351 |
Sealant - per tooth |
136 |
30 |
$5K |
| D2950 |
|
43 |
38 |
$4K |
| D1330 |
|
377 |
372 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
122 |
121 |
$1K |
| D4910 |
|
13 |
13 |
$702.00 |