| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,928 |
1,916 |
$166K |
| D0120 |
Periodic oral evaluation - established patient |
1,930 |
1,896 |
$114K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,098 |
1,090 |
$70K |
| D0274 |
Bitewings - four radiographic images |
2,827 |
2,804 |
$60K |
| D0230 |
Intraoral - periapical each additional radiographic image |
8,785 |
3,524 |
$56K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
921 |
551 |
$49K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
726 |
462 |
$47K |
| D1120 |
Prophylaxis - child |
860 |
847 |
$34K |
| D0350 |
|
2,537 |
1,389 |
$26K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
52 |
38 |
$25K |
| D9430 |
|
775 |
718 |
$25K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,362 |
1,346 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
739 |
690 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
49 |
38 |
$4K |
| D1351 |
Sealant - per tooth |
81 |
30 |
$3K |
| D9110 |
|
28 |
25 |
$2K |
| D2330 |
|
21 |
15 |
$2K |
| D2331 |
|
15 |
12 |
$1K |
| D0330 |
Panoramic radiographic image |
34 |
34 |
$1K |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$144.00 |