| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
897 |
793 |
$60K |
| D0120 |
Periodic oral evaluation - established patient |
1,315 |
1,170 |
$49K |
| D0274 |
Bitewings - four radiographic images |
922 |
818 |
$45K |
| D1120 |
Prophylaxis - child |
495 |
451 |
$27K |
| D1206 |
Topical application of fluoride varnish |
1,117 |
1,007 |
$27K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
197 |
87 |
$25K |
| D0330 |
Panoramic radiographic image |
292 |
258 |
$25K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
133 |
52 |
$21K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
228 |
197 |
$12K |
| D2740 |
Crown - porcelain/ceramic |
19 |
15 |
$12K |
| D2950 |
|
40 |
27 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
96 |
82 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
180 |
152 |
$4K |
| D0272 |
Bitewings - two radiographic images |
54 |
51 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
17 |
16 |
$390.88 |