| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,845 |
2,827 |
$155K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,336 |
671 |
$87K |
| D0230 |
Intraoral - periapical each additional radiographic image |
18,391 |
3,389 |
$77K |
| D1120 |
Prophylaxis - child |
2,079 |
2,072 |
$76K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,052 |
1,046 |
$65K |
| D1110 |
Prophylaxis - adult |
683 |
682 |
$57K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
847 |
405 |
$45K |
| D0272 |
Bitewings - two radiographic images |
3,010 |
2,998 |
$35K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,008 |
2,000 |
$22K |
| D4910 |
|
255 |
254 |
$19K |
| D0210 |
Intraoral - complete series of radiographic images |
350 |
348 |
$17K |
| D7140 |
Extraction, erupted tooth or exposed root |
265 |
132 |
$15K |
| D1206 |
Topical application of fluoride varnish |
631 |
629 |
$11K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
21 |
15 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
87 |
61 |
$7K |
| D0350 |
|
574 |
311 |
$5K |
| D1351 |
Sealant - per tooth |
127 |
28 |
$2K |
| D2954 |
|
17 |
12 |
$2K |
| D0274 |
Bitewings - four radiographic images |
63 |
63 |
$1K |
| D9430 |
|
13 |
13 |
$416.00 |
| D0220 |
Intraoral - periapical first radiographic image |
14 |
14 |
$156.00 |