| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,327 |
3,315 |
$206K |
| D0120 |
Periodic oral evaluation - established patient |
3,529 |
3,510 |
$185K |
| D1120 |
Prophylaxis - child |
3,120 |
3,095 |
$112K |
| D0210 |
Intraoral - complete series of radiographic images |
2,297 |
2,270 |
$102K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,472 |
851 |
$96K |
| D0230 |
Intraoral - periapical each additional radiographic image |
23,263 |
4,806 |
$94K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
955 |
575 |
$50K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,238 |
4,200 |
$48K |
| D1110 |
Prophylaxis - adult |
467 |
464 |
$40K |
| D2740 |
Crown - porcelain/ceramic |
46 |
28 |
$22K |
| D9430 |
|
642 |
625 |
$20K |
| D0274 |
Bitewings - four radiographic images |
811 |
808 |
$17K |
| D4910 |
|
179 |
177 |
$14K |
| D4341 |
|
155 |
43 |
$10K |
| D1351 |
Sealant - per tooth |
226 |
53 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
57 |
31 |
$4K |
| D0272 |
Bitewings - two radiographic images |
330 |
325 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
64 |
64 |
$2K |
| D0350 |
|
186 |
48 |
$2K |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$390.00 |
| D1206 |
Topical application of fluoride varnish |
13 |
13 |
$186.00 |
| D0431 |
|
30 |
30 |
$0.00 |