| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,348 |
1,341 |
$119K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,185 |
1,178 |
$78K |
| D0120 |
Periodic oral evaluation - established patient |
853 |
844 |
$65K |
| D0210 |
Intraoral - complete series of radiographic images |
1,110 |
1,104 |
$53K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,836 |
1,091 |
$29K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
419 |
227 |
$28K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,858 |
1,846 |
$26K |
| D1120 |
Prophylaxis - child |
480 |
480 |
$23K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
196 |
126 |
$16K |
| D0272 |
Bitewings - two radiographic images |
757 |
748 |
$9K |
| D2740 |
Crown - porcelain/ceramic |
17 |
13 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
132 |
70 |
$7K |
| D2335 |
|
41 |
24 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
263 |
261 |
$3K |
| D9430 |
|
70 |
69 |
$2K |
| D0350 |
|
85 |
47 |
$816.00 |