| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,566 |
2,520 |
$147K |
| D0120 |
Periodic oral evaluation - established patient |
5,114 |
5,028 |
$147K |
| D1206 |
Topical application of fluoride varnish |
4,900 |
4,829 |
$121K |
| D1120 |
Prophylaxis - child |
2,773 |
2,729 |
$116K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,083 |
856 |
$100K |
| D1351 |
Sealant - per tooth |
2,023 |
458 |
$67K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
518 |
408 |
$62K |
| D0274 |
Bitewings - four radiographic images |
1,283 |
1,258 |
$28K |
| D0330 |
Panoramic radiographic image |
626 |
617 |
$26K |
| D0272 |
Bitewings - two radiographic images |
1,256 |
1,233 |
$19K |
| D1330 |
|
2,583 |
2,535 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
142 |
137 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
26 |
25 |
$1K |
| D2940 |
|
14 |
12 |
$700.00 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$105.00 |