| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,698 |
2,672 |
$100K |
| D0120 |
Periodic oral evaluation - established patient |
3,482 |
3,435 |
$88K |
| D1110 |
Prophylaxis - adult |
1,521 |
1,498 |
$74K |
| D1206 |
Topical application of fluoride varnish |
2,248 |
2,225 |
$52K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
891 |
888 |
$32K |
| D0274 |
Bitewings - four radiographic images |
912 |
894 |
$26K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
210 |
125 |
$24K |
| D0210 |
Intraoral - complete series of radiographic images |
456 |
452 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
771 |
759 |
$12K |
| D2740 |
Crown - porcelain/ceramic |
17 |
12 |
$10K |
| D1351 |
Sealant - per tooth |
182 |
41 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
535 |
497 |
$5K |
| D2950 |
|
17 |
12 |
$3K |
| D0272 |
Bitewings - two radiographic images |
149 |
147 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
29 |
24 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$480.00 |