| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
4,519 |
4,507 |
$99K |
| D1110 |
Prophylaxis - adult |
4,341 |
4,329 |
$85K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
902 |
602 |
$37K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
981 |
528 |
$33K |
| D0140 |
Limited oral evaluation - problem focused |
1,623 |
1,597 |
$28K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,008 |
1,004 |
$25K |
| D0274 |
Bitewings - four radiographic images |
2,676 |
2,669 |
$24K |
| D0220 |
Intraoral - periapical first radiographic image |
5,347 |
5,248 |
$20K |
| D0210 |
Intraoral - complete series of radiographic images |
617 |
615 |
$18K |
| D1120 |
Prophylaxis - child |
959 |
956 |
$17K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,754 |
1,750 |
$16K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,025 |
3,979 |
$14K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
15 |
12 |
$5K |
| D0330 |
Panoramic radiographic image |
212 |
211 |
$3K |
| D1351 |
Sealant - per tooth |
92 |
13 |
$1K |
| D0272 |
Bitewings - two radiographic images |
179 |
179 |
$895.00 |
| D1999 |
|
69 |
67 |
$0.00 |