| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
4,133 |
4,081 |
$116K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,882 |
1,351 |
$92K |
| D0120 |
Periodic oral evaluation - established patient |
3,742 |
3,702 |
$76K |
| D1206 |
Topical application of fluoride varnish |
2,297 |
2,282 |
$60K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,105 |
744 |
$45K |
| D0274 |
Bitewings - four radiographic images |
2,835 |
2,804 |
$26K |
| D1120 |
Prophylaxis - child |
849 |
840 |
$25K |
| D2740 |
Crown - porcelain/ceramic |
59 |
51 |
$24K |
| D0210 |
Intraoral - complete series of radiographic images |
949 |
939 |
$24K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,539 |
1,520 |
$23K |
| D0140 |
Limited oral evaluation - problem focused |
780 |
771 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
4,422 |
4,354 |
$16K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,009 |
978 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,005 |
3,668 |
$13K |
| D1351 |
Sealant - per tooth |
516 |
90 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
60 |
54 |
$3K |
| D0603 |
|
329 |
329 |
$3K |
| D2950 |
|
28 |
24 |
$987.00 |
| D0330 |
Panoramic radiographic image |
26 |
26 |
$960.00 |
| D1353 |
|
92 |
14 |
$920.00 |
| D4341 |
|
28 |
12 |
$667.00 |
| D0601 |
|
13 |
13 |
$102.64 |
| D0272 |
Bitewings - two radiographic images |
17 |
17 |
$95.00 |
| D0270 |
|
14 |
14 |
$42.00 |
| D1330 |
|
138 |
121 |
$0.00 |