| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,553 |
1,546 |
$69K |
| D1206 |
Topical application of fluoride varnish |
2,081 |
2,047 |
$61K |
| D0120 |
Periodic oral evaluation - established patient |
2,008 |
2,003 |
$59K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
665 |
662 |
$29K |
| D1120 |
Prophylaxis - child |
626 |
625 |
$28K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
181 |
117 |
$13K |
| D0274 |
Bitewings - four radiographic images |
780 |
775 |
$9K |
| D1351 |
Sealant - per tooth |
453 |
65 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
1,705 |
1,671 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
168 |
167 |
$8K |
| D2740 |
Crown - porcelain/ceramic |
15 |
12 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,123 |
1,109 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
64 |
37 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
97 |
96 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
83 |
83 |
$2K |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$440.00 |
| D0272 |
Bitewings - two radiographic images |
44 |
44 |
$435.00 |