| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
11,715 |
11,712 |
$506K |
| D0120 |
Periodic oral evaluation - established patient |
15,458 |
15,454 |
$362K |
| D0274 |
Bitewings - four radiographic images |
9,975 |
9,975 |
$233K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,819 |
1,606 |
$196K |
| D0220 |
Intraoral - periapical first radiographic image |
15,656 |
15,648 |
$163K |
| D0230 |
Intraoral - periapical each additional radiographic image |
12,664 |
12,657 |
$149K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,565 |
939 |
$101K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,421 |
748 |
$67K |
| D1120 |
Prophylaxis - child |
1,418 |
1,418 |
$55K |
| D0210 |
Intraoral - complete series of radiographic images |
3,335 |
3,323 |
$49K |
| D1206 |
Topical application of fluoride varnish |
1,749 |
1,749 |
$45K |
| D1351 |
Sealant - per tooth |
658 |
213 |
$29K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,955 |
1,953 |
$24K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
42 |
33 |
$22K |
| D4341 |
|
194 |
104 |
$11K |
| D2394 |
|
50 |
39 |
$6K |
| D9945 |
|
31 |
31 |
$4K |
| D2331 |
|
18 |
12 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
110 |
110 |
$1K |