| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,758 |
1,750 |
$79K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,427 |
395 |
$77K |
| D1110 |
Prophylaxis - adult |
733 |
729 |
$59K |
| D0230 |
Intraoral - periapical each additional radiographic image |
10,600 |
2,144 |
$42K |
| D1120 |
Prophylaxis - child |
924 |
923 |
$31K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
539 |
536 |
$30K |
| D0350 |
|
2,431 |
641 |
$25K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
344 |
146 |
$23K |
| D0272 |
Bitewings - two radiographic images |
1,412 |
1,411 |
$16K |
| D0210 |
Intraoral - complete series of radiographic images |
339 |
337 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
868 |
850 |
$10K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
17 |
12 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
704 |
702 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
71 |
37 |
$4K |
| D9430 |
|
121 |
120 |
$4K |
| D1351 |
Sealant - per tooth |
76 |
26 |
$2K |
| D1330 |
|
18 |
18 |
$0.00 |
| D1310 |
|
20 |
20 |
$0.00 |