| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,584 |
4,470 |
$190K |
| D0120 |
Periodic oral evaluation - established patient |
5,166 |
5,042 |
$145K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,942 |
3,847 |
$102K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
716 |
527 |
$74K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
688 |
576 |
$49K |
| D0274 |
Bitewings - four radiographic images |
1,882 |
1,848 |
$35K |
| D1351 |
Sealant - per tooth |
367 |
256 |
$32K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,291 |
1,270 |
$32K |
| D1110 |
Prophylaxis - adult |
614 |
614 |
$30K |
| D0220 |
Intraoral - periapical first radiographic image |
4,138 |
3,948 |
$26K |
| D0210 |
Intraoral - complete series of radiographic images |
582 |
577 |
$19K |
| D0140 |
Limited oral evaluation - problem focused |
869 |
829 |
$16K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,162 |
3,061 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
262 |
240 |
$13K |
| D2740 |
Crown - porcelain/ceramic |
17 |
17 |
$5K |
| D0272 |
Bitewings - two radiographic images |
442 |
442 |
$5K |
| D4341 |
|
18 |
14 |
$4K |
| D0330 |
Panoramic radiographic image |
118 |
118 |
$3K |
| D2394 |
|
24 |
24 |
$2K |
| D2950 |
|
14 |
14 |
$1K |
| D4910 |
|
13 |
13 |
$737.00 |
| D1999 |
|
1,007 |
882 |
$0.00 |