| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,549 |
1,549 |
$43K |
| D1110 |
Prophylaxis - adult |
976 |
976 |
$27K |
| D1120 |
Prophylaxis - child |
771 |
771 |
$27K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
293 |
184 |
$16K |
| D2740 |
Crown - porcelain/ceramic |
29 |
24 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
273 |
132 |
$13K |
| D2954 |
|
112 |
92 |
$12K |
| D0274 |
Bitewings - four radiographic images |
568 |
568 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
317 |
279 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
594 |
594 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
187 |
187 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
140 |
140 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
277 |
240 |
$1K |
| D1351 |
Sealant - per tooth |
61 |
15 |
$1K |
| D1206 |
Topical application of fluoride varnish |
21 |
21 |
$433.23 |
| D0601 |
|
38 |
38 |
$380.00 |
| D0602 |
|
13 |
13 |
$130.00 |
| D1999 |
|
127 |
122 |
$0.00 |