| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
4,488 |
4,457 |
$170K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,863 |
1,685 |
$158K |
| D1208 |
Topical application of fluoride, excluding varnish |
6,350 |
6,300 |
$98K |
| D0120 |
Periodic oral evaluation - established patient |
5,369 |
5,323 |
$97K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,013 |
716 |
$77K |
| D1120 |
Prophylaxis - child |
2,245 |
2,223 |
$61K |
| D0330 |
Panoramic radiographic image |
1,031 |
1,023 |
$49K |
| D0272 |
Bitewings - two radiographic images |
2,443 |
2,430 |
$42K |
| D2330 |
|
713 |
435 |
$37K |
| D1351 |
Sealant - per tooth |
1,348 |
195 |
$27K |
| D2740 |
Crown - porcelain/ceramic |
59 |
52 |
$25K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
942 |
935 |
$24K |
| D0220 |
Intraoral - periapical first radiographic image |
1,340 |
1,314 |
$14K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
90 |
65 |
$6K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
12 |
12 |
$5K |
| D2331 |
|
18 |
14 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
27 |
27 |
$655.86 |