| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,706 |
1,695 |
$122K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,393 |
1,386 |
$91K |
| D1110 |
Prophylaxis - adult |
897 |
888 |
$79K |
| D1120 |
Prophylaxis - child |
1,448 |
1,440 |
$62K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
689 |
429 |
$45K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,880 |
2,860 |
$40K |
| D0210 |
Intraoral - complete series of radiographic images |
791 |
784 |
$37K |
| D0230 |
Intraoral - periapical each additional radiographic image |
8,966 |
2,246 |
$37K |
| D4910 |
|
417 |
412 |
$31K |
| D0274 |
Bitewings - four radiographic images |
1,058 |
1,050 |
$22K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
28 |
26 |
$13K |
| D4341 |
|
165 |
51 |
$12K |
| D9430 |
|
239 |
231 |
$8K |
| D0272 |
Bitewings - two radiographic images |
484 |
482 |
$6K |
| D1351 |
Sealant - per tooth |
202 |
45 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
456 |
445 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
71 |
49 |
$4K |
| D0350 |
|
304 |
200 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
33 |
24 |
$3K |
| D9993 |
|
12 |
12 |
$650.00 |
| D1310 |
|
12 |
12 |
$460.00 |