| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,076 |
2,074 |
$88K |
| D0120 |
Periodic oral evaluation - established patient |
2,161 |
2,155 |
$60K |
| D2740 |
Crown - porcelain/ceramic |
63 |
51 |
$35K |
| D0210 |
Intraoral - complete series of radiographic images |
747 |
745 |
$33K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
824 |
824 |
$33K |
| D1206 |
Topical application of fluoride varnish |
951 |
951 |
$30K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
182 |
123 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
441 |
439 |
$11K |
| D1120 |
Prophylaxis - child |
198 |
198 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
1,363 |
1,338 |
$6K |
| D0274 |
Bitewings - four radiographic images |
525 |
525 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
73 |
49 |
$6K |
| D1351 |
Sealant - per tooth |
271 |
43 |
$5K |
| D0350 |
|
25 |
25 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
933 |
931 |
$4K |
| D2954 |
|
19 |
13 |
$2K |
| D0330 |
Panoramic radiographic image |
42 |
42 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
122 |
118 |
$1K |
| D0272 |
Bitewings - two radiographic images |
41 |
41 |
$410.00 |