| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,956 |
1,947 |
$110K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,573 |
758 |
$103K |
| D1120 |
Prophylaxis - child |
1,851 |
1,850 |
$74K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
116 |
67 |
$55K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
790 |
786 |
$51K |
| D4910 |
|
467 |
463 |
$36K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
393 |
244 |
$31K |
| D0210 |
Intraoral - complete series of radiographic images |
661 |
661 |
$31K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,405 |
1,846 |
$30K |
| D9430 |
|
920 |
853 |
$29K |
| D0274 |
Bitewings - four radiographic images |
1,148 |
1,147 |
$23K |
| D1110 |
Prophylaxis - adult |
226 |
225 |
$20K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,346 |
1,343 |
$18K |
| D4341 |
|
135 |
40 |
$9K |
| D2952 |
|
37 |
24 |
$4K |
| D1351 |
Sealant - per tooth |
117 |
28 |
$4K |
| D1206 |
Topical application of fluoride varnish |
414 |
414 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
66 |
39 |
$3K |
| D0270 |
|
128 |
125 |
$616.25 |
| D0350 |
|
12 |
12 |
$105.60 |