| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,219 |
1,176 |
$42K |
| D1206 |
Topical application of fluoride varnish |
1,463 |
1,402 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
1,205 |
1,152 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
518 |
499 |
$11K |
| D0274 |
Bitewings - four radiographic images |
474 |
450 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
137 |
85 |
$9K |
| D2740 |
Crown - porcelain/ceramic |
14 |
12 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
578 |
541 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
91 |
91 |
$4K |
| D1120 |
Prophylaxis - child |
114 |
107 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
19 |
12 |
$986.40 |
| D0230 |
Intraoral - periapical each additional radiographic image |
67 |
53 |
$486.00 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$332.67 |