| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
13,493 |
13,483 |
$550K |
| D0120 |
Periodic oral evaluation - established patient |
17,963 |
17,949 |
$413K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
4,242 |
2,208 |
$322K |
| D0230 |
Intraoral - periapical each additional radiographic image |
16,778 |
16,758 |
$215K |
| D0274 |
Bitewings - four radiographic images |
8,188 |
8,186 |
$190K |
| D0220 |
Intraoral - periapical first radiographic image |
18,192 |
18,167 |
$167K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
217 |
122 |
$131K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,393 |
1,204 |
$129K |
| D1120 |
Prophylaxis - child |
2,348 |
2,345 |
$97K |
| D0210 |
Intraoral - complete series of radiographic images |
5,744 |
5,723 |
$86K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,160 |
698 |
$71K |
| D1206 |
Topical application of fluoride varnish |
2,468 |
2,468 |
$63K |
| D2954 |
|
363 |
218 |
$46K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,180 |
3,174 |
$43K |
| D1351 |
Sealant - per tooth |
359 |
171 |
$21K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
38 |
32 |
$15K |
| D2394 |
|
58 |
38 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
24 |
24 |
$569.04 |
| D0140 |
Limited oral evaluation - problem focused |
23 |
23 |
$245.72 |
| D0272 |
Bitewings - two radiographic images |
14 |
14 |
$180.42 |