| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
5,012 |
4,970 |
$78K |
| D1110 |
Prophylaxis - adult |
4,222 |
4,183 |
$64K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,016 |
1,183 |
$64K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,037 |
637 |
$28K |
| D1206 |
Topical application of fluoride varnish |
2,084 |
2,069 |
$25K |
| D1120 |
Prophylaxis - child |
2,006 |
1,994 |
$24K |
| D0274 |
Bitewings - four radiographic images |
2,830 |
2,813 |
$21K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,076 |
1,060 |
$20K |
| D0210 |
Intraoral - complete series of radiographic images |
823 |
809 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
3,843 |
3,744 |
$12K |
| D0140 |
Limited oral evaluation - problem focused |
708 |
690 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,141 |
1,125 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,532 |
3,145 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
112 |
86 |
$4K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
12 |
12 |
$4K |
| D1351 |
Sealant - per tooth |
122 |
15 |
$990.00 |
| D2950 |
|
15 |
12 |
$697.00 |
| D0601 |
|
17 |
17 |
$140.00 |