| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,557 |
2,556 |
$114K |
| D1206 |
Topical application of fluoride varnish |
3,090 |
3,085 |
$96K |
| D0120 |
Periodic oral evaluation - established patient |
3,065 |
3,061 |
$76K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
955 |
622 |
$64K |
| D1120 |
Prophylaxis - child |
995 |
995 |
$45K |
| D0210 |
Intraoral - complete series of radiographic images |
699 |
698 |
$31K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
538 |
341 |
$30K |
| D1351 |
Sealant - per tooth |
1,299 |
257 |
$26K |
| D0274 |
Bitewings - four radiographic images |
2,031 |
2,030 |
$24K |
| D0220 |
Intraoral - periapical first radiographic image |
2,753 |
2,746 |
$14K |
| D0140 |
Limited oral evaluation - problem focused |
297 |
295 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,348 |
2,342 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
492 |
492 |
$12K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
18 |
14 |
$9K |
| D0603 |
|
726 |
726 |
$7K |
| D1353 |
|
540 |
100 |
$5K |
| D0272 |
Bitewings - two radiographic images |
415 |
415 |
$4K |
| D0330 |
Panoramic radiographic image |
88 |
83 |
$3K |
| D0601 |
|
174 |
174 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
14 |
13 |
$1K |
| D2954 |
|
12 |
12 |
$1K |