| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,490 |
3,429 |
$185K |
| D0120 |
Periodic oral evaluation - established patient |
4,394 |
4,324 |
$108K |
| D0274 |
Bitewings - four radiographic images |
3,002 |
2,948 |
$105K |
| D1120 |
Prophylaxis - child |
1,617 |
1,599 |
$81K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,538 |
2,502 |
$73K |
| D0220 |
Intraoral - periapical first radiographic image |
3,838 |
3,749 |
$60K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,785 |
3,492 |
$49K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
579 |
573 |
$24K |
| D0330 |
Panoramic radiographic image |
927 |
913 |
$24K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
41 |
29 |
$22K |
| D1351 |
Sealant - per tooth |
535 |
152 |
$19K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
131 |
80 |
$11K |
| D0272 |
Bitewings - two radiographic images |
303 |
302 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
39 |
36 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
21 |
14 |
$1K |
| D1354 |
|
50 |
16 |
$750.00 |