| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
931 |
915 |
$26K |
| D1110 |
Prophylaxis - adult |
387 |
379 |
$20K |
| D1120 |
Prophylaxis - child |
574 |
565 |
$20K |
| D0274 |
Bitewings - four radiographic images |
440 |
433 |
$15K |
| D1208 |
Topical application of fluoride, excluding varnish |
968 |
951 |
$14K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
97 |
17 |
$12K |
| D0272 |
Bitewings - two radiographic images |
522 |
503 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
112 |
63 |
$11K |
| D0145 |
Oral evaluation for a patient under three years of age |
71 |
71 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
137 |
71 |
$10K |
| D1351 |
Sealant - per tooth |
287 |
96 |
$7K |
| D0350 |
|
308 |
285 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
425 |
408 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
269 |
200 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
71 |
64 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
26 |
25 |
$2K |
| D9420 |
|
24 |
21 |
$762.51 |
| D0330 |
Panoramic radiographic image |
17 |
17 |
$495.72 |
| D0140 |
Limited oral evaluation - problem focused |
29 |
29 |
$488.28 |
| D0603 |
|
1,183 |
1,163 |
$0.00 |