| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,227 |
1,217 |
$53K |
| D0120 |
Periodic oral evaluation - established patient |
1,717 |
1,706 |
$43K |
| D2740 |
Crown - porcelain/ceramic |
58 |
14 |
$42K |
| D0274 |
Bitewings - four radiographic images |
471 |
470 |
$14K |
| D0330 |
Panoramic radiographic image |
154 |
154 |
$10K |
| D4346 |
|
116 |
116 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
120 |
120 |
$5K |
| D1351 |
Sealant - per tooth |
133 |
12 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
183 |
182 |
$4K |
| D1120 |
Prophylaxis - child |
95 |
95 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
57 |
27 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
22 |
12 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
54 |
53 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
132 |
124 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
13 |
12 |
$146.25 |