| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
7,987 |
7,986 |
$326K |
| D0120 |
Periodic oral evaluation - established patient |
10,328 |
10,323 |
$233K |
| D0230 |
Intraoral - periapical each additional radiographic image |
9,814 |
9,809 |
$126K |
| D0220 |
Intraoral - periapical first radiographic image |
10,772 |
10,757 |
$101K |
| D0274 |
Bitewings - four radiographic images |
4,139 |
4,139 |
$97K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
150 |
84 |
$86K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
803 |
559 |
$72K |
| D0210 |
Intraoral - complete series of radiographic images |
4,206 |
4,199 |
$63K |
| D2954 |
|
402 |
255 |
$45K |
| D1120 |
Prophylaxis - child |
1,065 |
1,062 |
$40K |
| D1206 |
Topical application of fluoride varnish |
816 |
816 |
$21K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,719 |
1,716 |
$20K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
285 |
182 |
$20K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
144 |
102 |
$10K |
| D1351 |
Sealant - per tooth |
132 |
61 |
$8K |
| D2394 |
|
15 |
15 |
$2K |
| D0272 |
Bitewings - two radiographic images |
94 |
94 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$150.54 |