| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
3,354 |
3,350 |
$190K |
| D1120 |
Prophylaxis - child |
2,869 |
2,865 |
$111K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,533 |
879 |
$102K |
| D1110 |
Prophylaxis - adult |
973 |
973 |
$86K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,019 |
532 |
$55K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,717 |
3,709 |
$43K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
693 |
691 |
$43K |
| D0274 |
Bitewings - four radiographic images |
1,880 |
1,877 |
$40K |
| D0210 |
Intraoral - complete series of radiographic images |
681 |
680 |
$33K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,527 |
3,209 |
$28K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
168 |
118 |
$13K |
| D0272 |
Bitewings - two radiographic images |
1,104 |
1,103 |
$13K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
18 |
12 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
67 |
39 |
$4K |
| D1351 |
Sealant - per tooth |
43 |
12 |
$946.00 |
| D1320 |
|
47 |
47 |
$752.50 |