| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
6,493 |
6,489 |
$351K |
| D0120 |
Periodic oral evaluation - established patient |
9,752 |
9,746 |
$265K |
| D1120 |
Prophylaxis - child |
3,115 |
3,114 |
$131K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
821 |
743 |
$108K |
| D0274 |
Bitewings - four radiographic images |
2,936 |
2,935 |
$80K |
| D1208 |
Topical application of fluoride, excluding varnish |
5,073 |
5,071 |
$70K |
| D2740 |
Crown - porcelain/ceramic |
60 |
43 |
$44K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
102 |
100 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
172 |
172 |
$5K |
| D0330 |
Panoramic radiographic image |
114 |
114 |
$4K |
| D1206 |
Topical application of fluoride varnish |
116 |
116 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
133 |
131 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
26 |
24 |
$3K |
| D0272 |
Bitewings - two radiographic images |
100 |
100 |
$2K |
| D1351 |
Sealant - per tooth |
13 |
13 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
53 |
53 |
$697.48 |
| D1999 |
|
432 |
411 |
$0.00 |