| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0140 |
Limited oral evaluation - problem focused |
1,343 |
916 |
$57K |
| D1110 |
Prophylaxis - adult |
958 |
940 |
$50K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
795 |
782 |
$35K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
213 |
72 |
$21K |
| D0330 |
Panoramic radiographic image |
463 |
462 |
$20K |
| D0274 |
Bitewings - four radiographic images |
915 |
899 |
$18K |
| D1206 |
Topical application of fluoride varnish |
881 |
878 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
1,591 |
1,499 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,473 |
1,388 |
$14K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
23 |
17 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
236 |
236 |
$7K |
| D1351 |
Sealant - per tooth |
117 |
15 |
$4K |
| D1120 |
Prophylaxis - child |
69 |
69 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
22 |
15 |
$3K |
| D1330 |
|
656 |
570 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$276.00 |