| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,700 |
1,690 |
$79K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
450 |
253 |
$74K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
532 |
271 |
$73K |
| D0120 |
Periodic oral evaluation - established patient |
1,823 |
1,806 |
$46K |
| D0274 |
Bitewings - four radiographic images |
1,221 |
1,213 |
$37K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,697 |
1,678 |
$32K |
| D0220 |
Intraoral - periapical first radiographic image |
2,260 |
2,212 |
$29K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
399 |
398 |
$16K |
| D2740 |
Crown - porcelain/ceramic |
25 |
13 |
$11K |
| D1206 |
Topical application of fluoride varnish |
430 |
422 |
$10K |
| D4910 |
|
106 |
106 |
$7K |
| D0330 |
Panoramic radiographic image |
71 |
70 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
27 |
14 |
$3K |
| D1120 |
Prophylaxis - child |
51 |
51 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
51 |
51 |
$2K |