| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,405 |
1,399 |
$95K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,098 |
595 |
$73K |
| D0230 |
Intraoral - periapical each additional radiographic image |
15,524 |
2,815 |
$70K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,005 |
998 |
$64K |
| D4910 |
|
806 |
803 |
$62K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,062 |
468 |
$57K |
| D1120 |
Prophylaxis - child |
1,216 |
1,209 |
$52K |
| D1110 |
Prophylaxis - adult |
491 |
491 |
$42K |
| D4341 |
|
545 |
145 |
$38K |
| D9430 |
|
901 |
819 |
$29K |
| D0274 |
Bitewings - four radiographic images |
1,110 |
1,107 |
$24K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
34 |
27 |
$16K |
| D1206 |
Topical application of fluoride varnish |
1,014 |
1,014 |
$15K |
| D0272 |
Bitewings - two radiographic images |
1,240 |
1,233 |
$15K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,031 |
1,030 |
$12K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
117 |
80 |
$9K |
| D2954 |
|
18 |
12 |
$2K |
| D1351 |
Sealant - per tooth |
55 |
13 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
25 |
25 |
$288.00 |
| D0350 |
|
16 |
13 |
$108.00 |