| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,492 |
1,492 |
$39K |
| D1110 |
Prophylaxis - adult |
1,180 |
1,178 |
$27K |
| D1120 |
Prophylaxis - child |
709 |
708 |
$16K |
| D1206 |
Topical application of fluoride varnish |
829 |
828 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
364 |
364 |
$10K |
| D0274 |
Bitewings - four radiographic images |
912 |
912 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,524 |
1,522 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
280 |
280 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
174 |
116 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
1,725 |
1,706 |
$7K |
| D0191 |
|
465 |
420 |
$7K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
18 |
13 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
142 |
78 |
$6K |
| D0272 |
Bitewings - two radiographic images |
280 |
280 |
$1K |
| D1351 |
Sealant - per tooth |
68 |
13 |
$851.00 |
| D0140 |
Limited oral evaluation - problem focused |
36 |
36 |
$804.00 |
| D0350 |
|
86 |
86 |
$86.00 |