| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,214 |
1,207 |
$79K |
| D1110 |
Prophylaxis - adult |
552 |
551 |
$49K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
683 |
683 |
$44K |
| D1120 |
Prophylaxis - child |
859 |
857 |
$35K |
| D0210 |
Intraoral - complete series of radiographic images |
714 |
714 |
$34K |
| D2740 |
Crown - porcelain/ceramic |
66 |
52 |
$31K |
| D1206 |
Topical application of fluoride varnish |
1,641 |
1,634 |
$24K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,913 |
1,185 |
$16K |
| D0274 |
Bitewings - four radiographic images |
674 |
669 |
$14K |
| D4910 |
|
101 |
99 |
$8K |
| D9430 |
|
144 |
139 |
$5K |
| D2954 |
|
43 |
36 |
$5K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
36 |
29 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
60 |
46 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
41 |
30 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
92 |
91 |
$809.00 |
| D1351 |
Sealant - per tooth |
39 |
13 |
$770.00 |
| D0220 |
Intraoral - periapical first radiographic image |
36 |
36 |
$432.00 |