| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,051 |
3,038 |
$174K |
| D0120 |
Periodic oral evaluation - established patient |
3,539 |
3,532 |
$115K |
| D1206 |
Topical application of fluoride varnish |
3,347 |
3,339 |
$98K |
| D0274 |
Bitewings - four radiographic images |
2,145 |
2,139 |
$86K |
| D0330 |
Panoramic radiographic image |
1,029 |
1,028 |
$84K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
834 |
536 |
$74K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,027 |
543 |
$71K |
| D2740 |
Crown - porcelain/ceramic |
47 |
38 |
$54K |
| D2991 |
|
917 |
186 |
$54K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
546 |
349 |
$49K |
| D1351 |
Sealant - per tooth |
1,165 |
292 |
$41K |
| D2140 |
|
544 |
348 |
$38K |
| D9944 |
|
75 |
75 |
$36K |
| D1330 |
|
1,074 |
1,074 |
$35K |
| D1120 |
Prophylaxis - child |
788 |
788 |
$31K |
| D0140 |
Limited oral evaluation - problem focused |
560 |
549 |
$20K |
| D1354 |
|
548 |
224 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
1,131 |
1,104 |
$16K |
| D2330 |
|
129 |
80 |
$10K |
| D0272 |
Bitewings - two radiographic images |
194 |
193 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
600 |
357 |
$6K |
| D2331 |
|
49 |
27 |
$5K |
| D0350 |
|
81 |
81 |
$4K |
| D2160 |
|
36 |
27 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
79 |
79 |
$3K |
| D4910 |
|
17 |
17 |
$1K |