| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
5,547 |
5,547 |
$302K |
| D0120 |
Periodic oral evaluation - established patient |
6,285 |
6,285 |
$175K |
| D0274 |
Bitewings - four radiographic images |
5,670 |
5,670 |
$159K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
859 |
676 |
$94K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
134 |
110 |
$91K |
| D0220 |
Intraoral - periapical first radiographic image |
6,741 |
6,727 |
$91K |
| D1120 |
Prophylaxis - child |
1,820 |
1,820 |
$75K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,293 |
6,289 |
$62K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,036 |
3,036 |
$42K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,384 |
1,384 |
$40K |
| D0210 |
Intraoral - complete series of radiographic images |
1,452 |
1,443 |
$36K |
| D1351 |
Sealant - per tooth |
352 |
239 |
$34K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
431 |
354 |
$33K |
| D2954 |
|
168 |
126 |
$26K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
88 |
75 |
$14K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
71 |
42 |
$7K |
| D2332 |
|
24 |
24 |
$5K |
| D3320 |
|
16 |
13 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
324 |
321 |
$5K |
| D0330 |
Panoramic radiographic image |
74 |
74 |
$2K |
| D2140 |
|
14 |
13 |
$1K |
| D0272 |
Bitewings - two radiographic images |
75 |
75 |
$1K |
| D2330 |
|
20 |
13 |
$1K |
| D9110 |
|
12 |
12 |
$281.30 |
| D1999 |
|
113 |
110 |
$0.00 |