| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,968 |
1,951 |
$114K |
| D1120 |
Prophylaxis - child |
2,652 |
2,633 |
$104K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
878 |
869 |
$55K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
556 |
298 |
$35K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,752 |
2,731 |
$34K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,208 |
2,504 |
$30K |
| D0210 |
Intraoral - complete series of radiographic images |
643 |
635 |
$29K |
| D0274 |
Bitewings - four radiographic images |
1,046 |
1,037 |
$22K |
| D1110 |
Prophylaxis - adult |
204 |
201 |
$17K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
334 |
193 |
$17K |
| D0350 |
|
1,529 |
597 |
$15K |
| D1351 |
Sealant - per tooth |
280 |
88 |
$8K |
| D2740 |
Crown - porcelain/ceramic |
16 |
13 |
$8K |
| D0272 |
Bitewings - two radiographic images |
211 |
211 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
16 |
14 |
$1K |
| D1206 |
Topical application of fluoride varnish |
70 |
70 |
$1K |
| D4910 |
|
14 |
14 |
$1K |
| D9430 |
|
18 |
16 |
$576.00 |
| D0330 |
Panoramic radiographic image |
19 |
18 |
$540.00 |
| D0220 |
Intraoral - periapical first radiographic image |
39 |
38 |
$468.00 |