| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
4,172 |
4,160 |
$87K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,980 |
1,256 |
$82K |
| D1110 |
Prophylaxis - adult |
2,502 |
2,491 |
$52K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,429 |
4,408 |
$46K |
| D1120 |
Prophylaxis - child |
1,569 |
1,564 |
$40K |
| D0274 |
Bitewings - four radiographic images |
2,316 |
2,313 |
$31K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,216 |
3,918 |
$25K |
| D0220 |
Intraoral - periapical first radiographic image |
4,322 |
4,262 |
$18K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
471 |
344 |
$17K |
| D4346 |
|
441 |
438 |
$15K |
| D0210 |
Intraoral - complete series of radiographic images |
414 |
412 |
$13K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
27 |
25 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
485 |
485 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
476 |
460 |
$10K |
| D1351 |
Sealant - per tooth |
511 |
78 |
$8K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
146 |
108 |
$7K |
| D0272 |
Bitewings - two radiographic images |
752 |
749 |
$5K |
| D2331 |
|
34 |
24 |
$1K |
| D0602 |
|
48 |
47 |
$380.00 |
| D1999 |
|
12 |
12 |
$0.00 |