| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,743 |
1,670 |
$64K |
| D1206 |
Topical application of fluoride varnish |
3,410 |
3,178 |
$51K |
| D0120 |
Periodic oral evaluation - established patient |
2,423 |
2,283 |
$42K |
| D0274 |
Bitewings - four radiographic images |
1,247 |
1,189 |
$30K |
| D1120 |
Prophylaxis - child |
1,089 |
961 |
$28K |
| D0220 |
Intraoral - periapical first radiographic image |
1,958 |
1,817 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
526 |
514 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,389 |
1,052 |
$12K |
| D2740 |
Crown - porcelain/ceramic |
24 |
13 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
259 |
252 |
$7K |
| D0330 |
Panoramic radiographic image |
107 |
107 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
21 |
14 |
$2K |
| D1351 |
Sealant - per tooth |
48 |
13 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
16 |
12 |
$1K |
| D0272 |
Bitewings - two radiographic images |
57 |
55 |
$1K |
| D2140 |
|
21 |
12 |
$874.95 |
| D4910 |
|
13 |
13 |
$751.99 |