| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,444 |
1,228 |
$102K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
628 |
294 |
$88K |
| D0220 |
Intraoral - periapical first radiographic image |
2,623 |
2,288 |
$55K |
| D2740 |
Crown - porcelain/ceramic |
87 |
68 |
$52K |
| D0274 |
Bitewings - four radiographic images |
924 |
798 |
$46K |
| D0140 |
Limited oral evaluation - problem focused |
744 |
669 |
$43K |
| D0120 |
Periodic oral evaluation - established patient |
1,085 |
939 |
$42K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
348 |
173 |
$39K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
602 |
499 |
$31K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,132 |
949 |
$22K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
115 |
72 |
$20K |
| D0330 |
Panoramic radiographic image |
232 |
190 |
$18K |
| D1351 |
Sealant - per tooth |
198 |
29 |
$7K |
| D1206 |
Topical application of fluoride varnish |
259 |
212 |
$6K |
| D2950 |
|
29 |
24 |
$4K |
| D1120 |
Prophylaxis - child |
69 |
65 |
$4K |
| D2330 |
|
14 |
12 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
16 |
14 |
$866.56 |
| D0272 |
Bitewings - two radiographic images |
17 |
12 |
$447.92 |