| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,288 |
2,228 |
$95K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,532 |
664 |
$93K |
| D0330 |
Panoramic radiographic image |
1,532 |
1,496 |
$71K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,328 |
3,267 |
$69K |
| D0120 |
Periodic oral evaluation - established patient |
2,534 |
2,486 |
$60K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
102 |
65 |
$56K |
| D1120 |
Prophylaxis - child |
1,171 |
1,152 |
$39K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,241 |
1,209 |
$35K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
453 |
257 |
$33K |
| D0274 |
Bitewings - four radiographic images |
1,202 |
1,187 |
$32K |
| D0220 |
Intraoral - periapical first radiographic image |
914 |
849 |
$11K |
| D1351 |
Sealant - per tooth |
181 |
57 |
$5K |
| D9110 |
|
47 |
47 |
$2K |
| D0272 |
Bitewings - two radiographic images |
114 |
113 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
19 |
14 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
91 |
67 |
$495.80 |