| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,517 |
1,516 |
$66K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
561 |
435 |
$44K |
| D0210 |
Intraoral - complete series of radiographic images |
1,647 |
1,646 |
$33K |
| D0120 |
Periodic oral evaluation - established patient |
1,258 |
1,257 |
$29K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,191 |
1,190 |
$28K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
369 |
298 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
1,278 |
1,276 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
257 |
257 |
$6K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
13 |
12 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
14 |
14 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
107 |
107 |
$1K |
| D2954 |
|
13 |
13 |
$1K |
| D1120 |
Prophylaxis - child |
13 |
13 |
$413.95 |