| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,013 |
2,001 |
$133K |
| D1120 |
Prophylaxis - child |
1,669 |
1,668 |
$83K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,042 |
555 |
$70K |
| D0210 |
Intraoral - complete series of radiographic images |
1,292 |
1,289 |
$62K |
| D1206 |
Topical application of fluoride varnish |
2,450 |
2,446 |
$50K |
| D0120 |
Periodic oral evaluation - established patient |
593 |
592 |
$38K |
| D1351 |
Sealant - per tooth |
999 |
233 |
$38K |
| D1110 |
Prophylaxis - adult |
352 |
352 |
$31K |
| D1310 |
|
733 |
732 |
$31K |
| D4341 |
|
421 |
119 |
$29K |
| D7140 |
Extraction, erupted tooth or exposed root |
498 |
242 |
$29K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
487 |
299 |
$26K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,869 |
969 |
$12K |
| D0350 |
|
1,215 |
541 |
$11K |
| D4910 |
|
133 |
133 |
$10K |
| D0145 |
Oral evaluation for a patient under three years of age |
147 |
146 |
$9K |
| D0274 |
Bitewings - four radiographic images |
415 |
414 |
$8K |
| D1320 |
|
492 |
492 |
$8K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
17 |
12 |
$8K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
73 |
54 |
$6K |
| D0602 |
|
315 |
315 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
233 |
233 |
$3K |
| D2954 |
|
21 |
14 |
$2K |
| D0603 |
|
153 |
153 |
$2K |
| D2330 |
|
17 |
12 |
$1K |
| D0272 |
Bitewings - two radiographic images |
14 |
14 |
$169.00 |
| D0601 |
|
13 |
13 |
$165.00 |