| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,292 |
1,289 |
$63K |
| D1120 |
Prophylaxis - child |
1,627 |
1,627 |
$62K |
| D0120 |
Periodic oral evaluation - established patient |
2,354 |
2,352 |
$60K |
| D2740 |
Crown - porcelain/ceramic |
77 |
38 |
$52K |
| D1206 |
Topical application of fluoride varnish |
2,081 |
2,080 |
$49K |
| D2394 |
|
139 |
80 |
$25K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
167 |
107 |
$24K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
535 |
535 |
$23K |
| D2950 |
|
123 |
71 |
$21K |
| D0274 |
Bitewings - four radiographic images |
581 |
581 |
$17K |
| D0210 |
Intraoral - complete series of radiographic images |
174 |
174 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
544 |
529 |
$8K |
| D1351 |
Sealant - per tooth |
275 |
89 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
176 |
173 |
$7K |
| D0272 |
Bitewings - two radiographic images |
179 |
179 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
300 |
225 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
13 |
12 |
$1K |