| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
5,631 |
5,595 |
$313K |
| D1120 |
Prophylaxis - child |
4,914 |
4,894 |
$184K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,313 |
2,309 |
$145K |
| D0230 |
Intraoral - periapical each additional radiographic image |
16,484 |
6,529 |
$130K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,711 |
1,033 |
$113K |
| D0210 |
Intraoral - complete series of radiographic images |
2,171 |
2,164 |
$101K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,708 |
1,081 |
$92K |
| D1110 |
Prophylaxis - adult |
1,034 |
1,022 |
$88K |
| D1208 |
Topical application of fluoride, excluding varnish |
5,949 |
5,922 |
$68K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
120 |
92 |
$57K |
| D0274 |
Bitewings - four radiographic images |
2,469 |
2,444 |
$52K |
| D1351 |
Sealant - per tooth |
1,533 |
384 |
$43K |
| D4910 |
|
494 |
493 |
$38K |
| D4341 |
|
532 |
150 |
$37K |
| D9430 |
|
1,052 |
1,030 |
$34K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
405 |
264 |
$27K |
| D0272 |
Bitewings - two radiographic images |
2,228 |
2,224 |
$26K |
| D2140 |
|
123 |
70 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
83 |
53 |
$6K |
| D0350 |
|
586 |
446 |
$6K |
| D2954 |
|
41 |
27 |
$4K |
| D1310 |
|
52 |
52 |
$1K |
| D0270 |
|
148 |
148 |
$725.00 |
| D0603 |
|
25 |
25 |
$375.00 |
| D9993 |
|
27 |
27 |
$0.00 |