| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
5,622 |
5,614 |
$225K |
| D0120 |
Periodic oral evaluation - established patient |
7,036 |
7,032 |
$153K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,287 |
810 |
$120K |
| D0274 |
Bitewings - four radiographic images |
5,070 |
5,069 |
$110K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,603 |
6,595 |
$81K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
573 |
443 |
$59K |
| D0220 |
Intraoral - periapical first radiographic image |
6,717 |
6,709 |
$57K |
| D2750 |
|
159 |
100 |
$49K |
| D1120 |
Prophylaxis - child |
877 |
877 |
$32K |
| D0210 |
Intraoral - complete series of radiographic images |
5,181 |
5,173 |
$32K |
| D2954 |
|
211 |
189 |
$29K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
55 |
42 |
$24K |
| D1351 |
Sealant - per tooth |
476 |
204 |
$23K |
| D1206 |
Topical application of fluoride varnish |
851 |
851 |
$22K |
| D2791 |
|
41 |
38 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
266 |
133 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
150 |
150 |
$4K |
| D0272 |
Bitewings - two radiographic images |
201 |
201 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
231 |
231 |
$592.30 |
| D1999 |
|
80 |
78 |
$0.00 |