| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
6,114 |
6,112 |
$265K |
| D0120 |
Periodic oral evaluation - established patient |
8,823 |
8,821 |
$194K |
| D0274 |
Bitewings - four radiographic images |
7,190 |
7,190 |
$158K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
361 |
304 |
$156K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,195 |
1,526 |
$132K |
| D0220 |
Intraoral - periapical first radiographic image |
9,166 |
9,145 |
$97K |
| D1120 |
Prophylaxis - child |
2,607 |
2,607 |
$85K |
| D9990 |
|
3,065 |
2,621 |
$64K |
| D0230 |
Intraoral - periapical each additional radiographic image |
9,108 |
9,068 |
$56K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,683 |
4,683 |
$52K |
| D1351 |
Sealant - per tooth |
890 |
382 |
$45K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
987 |
708 |
$37K |
| D2954 |
|
139 |
116 |
$15K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
15 |
15 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
79 |
69 |
$5K |
| D0272 |
Bitewings - two radiographic images |
342 |
342 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
397 |
397 |
$4K |
| D1354 |
|
168 |
69 |
$3K |
| D2335 |
|
19 |
12 |
$3K |
| D2331 |
|
18 |
12 |
$1K |
| D9110 |
|
35 |
33 |
$657.32 |