| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
3,289 |
3,278 |
$89K |
| D1351 |
Sealant - per tooth |
3,667 |
690 |
$84K |
| D1110 |
Prophylaxis - adult |
2,019 |
2,011 |
$80K |
| D1120 |
Prophylaxis - child |
2,156 |
2,153 |
$63K |
| D1206 |
Topical application of fluoride varnish |
1,934 |
1,929 |
$48K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
529 |
201 |
$37K |
| D0274 |
Bitewings - four radiographic images |
2,331 |
2,319 |
$31K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
961 |
961 |
$27K |
| D0330 |
Panoramic radiographic image |
634 |
633 |
$24K |
| D0220 |
Intraoral - periapical first radiographic image |
4,296 |
4,249 |
$23K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
40 |
25 |
$19K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,868 |
3,834 |
$18K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,196 |
1,196 |
$18K |
| D2750 |
|
31 |
25 |
$17K |
| D7111 |
|
428 |
268 |
$16K |
| D0272 |
Bitewings - two radiographic images |
960 |
960 |
$8K |
| D2954 |
|
77 |
55 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
213 |
212 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
76 |
76 |
$3K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
25 |
12 |
$3K |
| D2950 |
|
39 |
30 |
$2K |
| D1330 |
|
454 |
433 |
$0.00 |