| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,496 |
2,478 |
$139K |
| D1110 |
Prophylaxis - adult |
1,522 |
1,513 |
$131K |
| D0230 |
Intraoral - periapical each additional radiographic image |
16,463 |
3,432 |
$66K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
923 |
447 |
$62K |
| D1120 |
Prophylaxis - child |
1,582 |
1,570 |
$58K |
| D0220 |
Intraoral - periapical first radiographic image |
3,577 |
3,309 |
$42K |
| D1206 |
Topical application of fluoride varnish |
2,698 |
2,677 |
$40K |
| D4910 |
|
360 |
360 |
$28K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
419 |
419 |
$25K |
| D9110 |
|
366 |
336 |
$23K |
| D0330 |
Panoramic radiographic image |
722 |
719 |
$21K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
44 |
32 |
$21K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
316 |
184 |
$21K |
| D0350 |
|
2,091 |
690 |
$20K |
| D9430 |
|
604 |
515 |
$19K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
216 |
135 |
$17K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
271 |
129 |
$15K |
| D0210 |
Intraoral - complete series of radiographic images |
175 |
170 |
$8K |
| D2330 |
|
106 |
53 |
$8K |
| D4341 |
|
101 |
27 |
$7K |
| D2140 |
|
116 |
69 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
528 |
528 |
$5K |
| D2160 |
|
52 |
38 |
$4K |
| D1351 |
Sealant - per tooth |
41 |
13 |
$2K |
| D0272 |
Bitewings - two radiographic images |
65 |
65 |
$732.00 |