| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,750 |
1,744 |
$78K |
| D1206 |
Topical application of fluoride varnish |
1,834 |
1,828 |
$57K |
| D0120 |
Periodic oral evaluation - established patient |
1,730 |
1,724 |
$43K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
445 |
268 |
$31K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
485 |
286 |
$27K |
| D0210 |
Intraoral - complete series of radiographic images |
404 |
404 |
$18K |
| D0274 |
Bitewings - four radiographic images |
1,269 |
1,264 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
1,551 |
1,542 |
$8K |
| D1120 |
Prophylaxis - child |
167 |
167 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,242 |
1,233 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
164 |
162 |
$7K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
19 |
14 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
216 |
216 |
$5K |
| D1351 |
Sealant - per tooth |
175 |
36 |
$4K |
| D0330 |
Panoramic radiographic image |
83 |
83 |
$3K |
| D2950 |
|
42 |
28 |
$1K |
| D0603 |
|
121 |
121 |
$1K |