| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,186 |
1,178 |
$77K |
| D0120 |
Periodic oral evaluation - established patient |
767 |
762 |
$50K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
609 |
331 |
$40K |
| D0230 |
Intraoral - periapical each additional radiographic image |
9,449 |
1,773 |
$39K |
| D1120 |
Prophylaxis - child |
906 |
900 |
$38K |
| D0210 |
Intraoral - complete series of radiographic images |
654 |
651 |
$31K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
321 |
181 |
$17K |
| D0272 |
Bitewings - two radiographic images |
1,433 |
1,420 |
$17K |
| D8670 |
Periodic orthodontic treatment visit |
38 |
38 |
$11K |
| D1110 |
Prophylaxis - adult |
115 |
115 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
747 |
739 |
$9K |
| D4910 |
|
109 |
109 |
$8K |
| D4341 |
|
111 |
30 |
$8K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
13 |
12 |
$6K |
| D9430 |
|
101 |
100 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
38 |
27 |
$3K |
| D0330 |
Panoramic radiographic image |
101 |
99 |
$3K |
| D4342 |
|
53 |
15 |
$2K |
| D1351 |
Sealant - per tooth |
48 |
13 |
$2K |
| D1310 |
|
12 |
12 |
$536.00 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$420.00 |
| D0603 |
|
12 |
12 |
$180.00 |