| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,084 |
1,081 |
$48K |
| D1206 |
Topical application of fluoride varnish |
845 |
841 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
911 |
911 |
$22K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
225 |
141 |
$16K |
| D2740 |
Crown - porcelain/ceramic |
19 |
12 |
$10K |
| D0274 |
Bitewings - four radiographic images |
439 |
439 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
204 |
204 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
112 |
111 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
738 |
735 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
64 |
44 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
531 |
530 |
$3K |
| D2950 |
|
21 |
13 |
$1K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
13 |
12 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$540.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
16 |
16 |
$400.00 |
| D0603 |
|
27 |
27 |
$270.00 |