| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,768 |
3,768 |
$209K |
| D0120 |
Periodic oral evaluation - established patient |
4,404 |
4,404 |
$123K |
| D0210 |
Intraoral - complete series of radiographic images |
3,771 |
3,588 |
$87K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,306 |
4,299 |
$72K |
| D0220 |
Intraoral - periapical first radiographic image |
5,133 |
5,058 |
$68K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
593 |
543 |
$61K |
| D1120 |
Prophylaxis - child |
1,204 |
1,204 |
$51K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,219 |
2,219 |
$31K |
| D1351 |
Sealant - per tooth |
230 |
201 |
$25K |
| D0272 |
Bitewings - two radiographic images |
1,025 |
1,023 |
$17K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
28 |
25 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
535 |
535 |
$16K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
189 |
165 |
$13K |
| D0140 |
Limited oral evaluation - problem focused |
820 |
800 |
$10K |
| D0270 |
|
205 |
196 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
15 |
14 |
$2K |
| D2331 |
|
12 |
12 |
$1K |
| D1206 |
Topical application of fluoride varnish |
29 |
29 |
$870.00 |
| D1999 |
|
55 |
53 |
$0.00 |