| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,873 |
1,869 |
$168K |
| D0120 |
Periodic oral evaluation - established patient |
1,880 |
1,879 |
$145K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,128 |
2,126 |
$141K |
| D1120 |
Prophylaxis - child |
1,801 |
1,801 |
$82K |
| D1351 |
Sealant - per tooth |
2,305 |
470 |
$77K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,688 |
3,680 |
$54K |
| D9430 |
|
1,626 |
1,589 |
$52K |
| D0274 |
Bitewings - four radiographic images |
2,337 |
2,335 |
$50K |
| D0210 |
Intraoral - complete series of radiographic images |
929 |
928 |
$45K |
| D0230 |
Intraoral - periapical each additional radiographic image |
10,679 |
2,944 |
$43K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
638 |
264 |
$35K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
66 |
53 |
$31K |
| D0220 |
Intraoral - periapical first radiographic image |
1,445 |
1,379 |
$17K |
| D2330 |
|
172 |
69 |
$13K |
| D1320 |
|
521 |
521 |
$9K |
| D0350 |
|
663 |
276 |
$6K |
| D0272 |
Bitewings - two radiographic images |
416 |
416 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
43 |
26 |
$3K |
| D1310 |
|
12 |
12 |
$552.00 |