| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,781 |
1,766 |
$145K |
| D1110 |
Prophylaxis - adult |
1,250 |
1,250 |
$111K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,518 |
1,518 |
$100K |
| D4910 |
|
1,260 |
1,250 |
$96K |
| D4341 |
|
823 |
232 |
$57K |
| D1120 |
Prophylaxis - child |
1,137 |
1,129 |
$54K |
| D0210 |
Intraoral - complete series of radiographic images |
1,040 |
1,040 |
$50K |
| D1206 |
Topical application of fluoride varnish |
2,820 |
2,796 |
$46K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
674 |
551 |
$45K |
| D2740 |
Crown - porcelain/ceramic |
61 |
57 |
$29K |
| D0274 |
Bitewings - four radiographic images |
1,280 |
1,274 |
$27K |
| D9430 |
|
533 |
515 |
$17K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,497 |
1,154 |
$14K |
| D1351 |
Sealant - per tooth |
197 |
40 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
69 |
56 |
$6K |
| D0350 |
|
566 |
116 |
$4K |
| D4342 |
|
44 |
15 |
$2K |
| D2954 |
|
14 |
13 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
17 |
14 |
$928.20 |
| D0272 |
Bitewings - two radiographic images |
48 |
47 |
$540.00 |
| D0220 |
Intraoral - periapical first radiographic image |
39 |
39 |
$468.00 |