| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,982 |
1,964 |
$107K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,605 |
1,599 |
$102K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
903 |
388 |
$59K |
| D1120 |
Prophylaxis - child |
1,467 |
1,443 |
$51K |
| D0210 |
Intraoral - complete series of radiographic images |
1,061 |
1,049 |
$48K |
| D0274 |
Bitewings - four radiographic images |
1,981 |
1,963 |
$41K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
757 |
311 |
$40K |
| D2740 |
Crown - porcelain/ceramic |
74 |
57 |
$35K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,045 |
2,802 |
$24K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,240 |
1,226 |
$12K |
| D9430 |
|
319 |
319 |
$10K |
| D2954 |
|
84 |
67 |
$9K |
| D1351 |
Sealant - per tooth |
326 |
66 |
$6K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
51 |
37 |
$6K |
| D4910 |
|
51 |
51 |
$4K |
| D0272 |
Bitewings - two radiographic images |
45 |
45 |
$466.00 |
| D1206 |
Topical application of fluoride varnish |
47 |
47 |
$432.00 |
| D0220 |
Intraoral - periapical first radiographic image |
13 |
13 |
$130.00 |