| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
5,112 |
5,102 |
$296K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
601 |
383 |
$286K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,876 |
1,127 |
$192K |
| D1120 |
Prophylaxis - child |
4,478 |
4,472 |
$175K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,443 |
2,437 |
$152K |
| D1110 |
Prophylaxis - adult |
1,698 |
1,696 |
$149K |
| D4910 |
|
1,945 |
1,943 |
$148K |
| D0230 |
Intraoral - periapical each additional radiographic image |
26,398 |
7,049 |
$108K |
| D9110 |
|
1,688 |
1,600 |
$105K |
| D0274 |
Bitewings - four radiographic images |
4,191 |
4,183 |
$89K |
| D4341 |
|
1,040 |
281 |
$72K |
| D0210 |
Intraoral - complete series of radiographic images |
1,380 |
1,377 |
$65K |
| D1206 |
Topical application of fluoride varnish |
4,587 |
4,580 |
$55K |
| D0272 |
Bitewings - two radiographic images |
2,462 |
2,457 |
$29K |
| D0220 |
Intraoral - periapical first radiographic image |
1,749 |
1,684 |
$21K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
217 |
104 |
$17K |
| D9430 |
|
332 |
280 |
$11K |
| D1351 |
Sealant - per tooth |
230 |
53 |
$7K |
| D1310 |
|
144 |
144 |
$7K |
| D9993 |
|
87 |
87 |
$6K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
39 |
39 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
27 |
13 |
$1K |
| D0350 |
|
141 |
83 |
$1K |
| D4342 |
|
29 |
12 |
$1K |
| D0145 |
Oral evaluation for a patient under three years of age |
12 |
12 |
$308.00 |
| D0601 |
|
15 |
15 |
$225.00 |