| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,817 |
2,805 |
$252K |
| D4910 |
|
3,255 |
3,251 |
$250K |
| D0120 |
Periodic oral evaluation - established patient |
3,138 |
3,129 |
$225K |
| D4341 |
|
2,396 |
685 |
$168K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,623 |
1,615 |
$107K |
| D1120 |
Prophylaxis - child |
1,840 |
1,834 |
$82K |
| D0274 |
Bitewings - four radiographic images |
3,783 |
3,776 |
$81K |
| D0230 |
Intraoral - periapical each additional radiographic image |
19,017 |
5,660 |
$79K |
| D1206 |
Topical application of fluoride varnish |
4,028 |
4,005 |
$68K |
| D0210 |
Intraoral - complete series of radiographic images |
1,138 |
1,133 |
$54K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
85 |
55 |
$40K |
| D9430 |
|
1,207 |
1,170 |
$39K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
647 |
405 |
$35K |
| D2330 |
|
364 |
209 |
$28K |
| D0220 |
Intraoral - periapical first radiographic image |
1,594 |
1,549 |
$19K |
| D1310 |
|
425 |
424 |
$19K |
| D1208 |
Topical application of fluoride, excluding varnish |
998 |
998 |
$13K |
| D1351 |
Sealant - per tooth |
342 |
79 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
127 |
78 |
$7K |
| D0603 |
|
425 |
424 |
$6K |
| D0272 |
Bitewings - two radiographic images |
463 |
462 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
61 |
46 |
$4K |
| D0330 |
Panoramic radiographic image |
93 |
93 |
$3K |
| D0350 |
|
204 |
90 |
$2K |
| D4342 |
|
32 |
12 |
$1K |
| D0240 |
|
104 |
52 |
$1K |
| D9993 |
|
25 |
25 |
$780.00 |