| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,206 |
1,193 |
$108K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,230 |
1,219 |
$81K |
| D0210 |
Intraoral - complete series of radiographic images |
868 |
868 |
$41K |
| D0120 |
Periodic oral evaluation - established patient |
428 |
426 |
$34K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
366 |
192 |
$29K |
| D2740 |
Crown - porcelain/ceramic |
57 |
42 |
$27K |
| D1206 |
Topical application of fluoride varnish |
1,357 |
1,342 |
$23K |
| D2394 |
|
192 |
101 |
$16K |
| D4341 |
|
214 |
57 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,699 |
574 |
$14K |
| D0274 |
Bitewings - four radiographic images |
281 |
280 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
89 |
42 |
$6K |
| D4910 |
|
70 |
70 |
$5K |
| D1120 |
Prophylaxis - child |
39 |
39 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
34 |
33 |
$474.00 |
| D0220 |
Intraoral - periapical first radiographic image |
25 |
25 |
$300.00 |