| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,494 |
2,488 |
$147K |
| D1110 |
Prophylaxis - adult |
1,139 |
1,136 |
$102K |
| D1120 |
Prophylaxis - child |
1,788 |
1,783 |
$71K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
760 |
760 |
$48K |
| D0210 |
Intraoral - complete series of radiographic images |
1,022 |
1,022 |
$48K |
| D1206 |
Topical application of fluoride varnish |
3,184 |
3,175 |
$45K |
| D4910 |
|
551 |
549 |
$42K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
200 |
88 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,581 |
644 |
$10K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
17 |
14 |
$8K |
| D1351 |
Sealant - per tooth |
113 |
25 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
52 |
38 |
$4K |
| D4341 |
|
48 |
12 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
42 |
26 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
156 |
156 |
$2K |
| D0272 |
Bitewings - two radiographic images |
97 |
97 |
$1K |
| D1999 |
|
16 |
13 |
$46.00 |