| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
3,236 |
3,220 |
$202K |
| D2740 |
Crown - porcelain/ceramic |
291 |
220 |
$138K |
| D1120 |
Prophylaxis - child |
3,301 |
3,282 |
$132K |
| D1110 |
Prophylaxis - adult |
1,402 |
1,401 |
$124K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,841 |
1,840 |
$114K |
| D4910 |
|
1,109 |
1,109 |
$85K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,274 |
740 |
$84K |
| D1206 |
Topical application of fluoride varnish |
4,007 |
3,985 |
$58K |
| D0210 |
Intraoral - complete series of radiographic images |
1,057 |
1,056 |
$50K |
| D9430 |
|
1,276 |
1,165 |
$40K |
| D0274 |
Bitewings - four radiographic images |
1,771 |
1,761 |
$37K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
429 |
311 |
$34K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,601 |
2,664 |
$30K |
| D2954 |
|
261 |
196 |
$27K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
437 |
282 |
$24K |
| D4341 |
|
322 |
88 |
$22K |
| D0350 |
|
1,590 |
877 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
899 |
860 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
770 |
763 |
$8K |
| D1351 |
Sealant - per tooth |
284 |
82 |
$8K |
| D0330 |
Panoramic radiographic image |
51 |
51 |
$1K |
| D9110 |
|
14 |
12 |
$882.00 |
| D0272 |
Bitewings - two radiographic images |
67 |
67 |
$804.00 |
| D1999 |
|
1,851 |
1,520 |
$690.00 |