| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
6,799 |
6,790 |
$350K |
| D0120 |
Periodic oral evaluation - established patient |
6,196 |
6,191 |
$185K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,021 |
1,473 |
$175K |
| D2740 |
Crown - porcelain/ceramic |
173 |
140 |
$114K |
| D1120 |
Prophylaxis - child |
1,084 |
1,083 |
$58K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,221 |
654 |
$57K |
| D0210 |
Intraoral - complete series of radiographic images |
1,015 |
1,010 |
$54K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,284 |
1,282 |
$37K |
| D0140 |
Limited oral evaluation - problem focused |
669 |
654 |
$35K |
| D0274 |
Bitewings - four radiographic images |
3,127 |
3,122 |
$32K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,077 |
1,077 |
$29K |
| D0220 |
Intraoral - periapical first radiographic image |
4,455 |
4,341 |
$24K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
230 |
158 |
$16K |
| D0330 |
Panoramic radiographic image |
858 |
852 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,229 |
2,872 |
$10K |
| D1351 |
Sealant - per tooth |
181 |
32 |
$4K |
| D2950 |
|
62 |
54 |
$4K |
| D9944 |
|
51 |
51 |
$4K |
| D9940 |
|
27 |
27 |
$2K |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$420.00 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$144.00 |
| D1330 |
|
50 |
50 |
$0.00 |
| D1999 |
|
29 |
29 |
$0.00 |