| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D4910 |
|
908 |
896 |
$121K |
| D1120 |
Prophylaxis - child |
2,560 |
2,521 |
$100K |
| D0120 |
Periodic oral evaluation - established patient |
2,291 |
2,277 |
$94K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,988 |
1,940 |
$94K |
| D9430 |
|
3,111 |
2,660 |
$89K |
| D1206 |
Topical application of fluoride varnish |
3,641 |
3,569 |
$88K |
| D0274 |
Bitewings - four radiographic images |
2,596 |
2,567 |
$52K |
| D0220 |
Intraoral - periapical first radiographic image |
4,103 |
4,001 |
$46K |
| D0210 |
Intraoral - complete series of radiographic images |
1,008 |
983 |
$42K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,915 |
3,502 |
$27K |
| D1110 |
Prophylaxis - adult |
266 |
261 |
$21K |
| D4341 |
|
308 |
94 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
232 |
160 |
$11K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
153 |
107 |
$9K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
18 |
15 |
$9K |
| D1351 |
Sealant - per tooth |
226 |
49 |
$7K |
| D9999 |
Unspecified adjunctive procedure, by report |
76 |
76 |
$3K |
| D0999 |
Unspecified diagnostic procedure, by report |
50 |
50 |
$3K |
| D2335 |
|
24 |
12 |
$3K |
| D0272 |
Bitewings - two radiographic images |
189 |
188 |
$2K |
| D1999 |
|
28 |
28 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
56 |
25 |
$1K |
| D0270 |
|
158 |
157 |
$775.00 |
| D9986 |
|
12 |
12 |
$0.00 |