| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,521 |
2,509 |
$176K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,281 |
2,276 |
$151K |
| D1120 |
Prophylaxis - child |
2,856 |
2,842 |
$133K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,684 |
906 |
$112K |
| D1110 |
Prophylaxis - adult |
785 |
785 |
$70K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,227 |
627 |
$67K |
| D0210 |
Intraoral - complete series of radiographic images |
1,402 |
1,399 |
$65K |
| D4910 |
|
617 |
613 |
$47K |
| D2740 |
Crown - porcelain/ceramic |
74 |
58 |
$35K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,112 |
2,110 |
$28K |
| D4341 |
|
368 |
94 |
$26K |
| D1206 |
Topical application of fluoride varnish |
1,327 |
1,312 |
$22K |
| D0350 |
|
2,460 |
1,033 |
$22K |
| D0274 |
Bitewings - four radiographic images |
886 |
883 |
$17K |
| D1351 |
Sealant - per tooth |
437 |
117 |
$16K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,860 |
780 |
$12K |
| D9430 |
|
349 |
328 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
601 |
597 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
19 |
13 |
$2K |
| D0330 |
Panoramic radiographic image |
47 |
47 |
$1K |
| D1310 |
|
27 |
25 |
$1K |
| D0272 |
Bitewings - two radiographic images |
16 |
16 |
$192.00 |