| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
3,301 |
3,297 |
$171K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,666 |
1,666 |
$102K |
| D1120 |
Prophylaxis - child |
2,530 |
2,525 |
$95K |
| D1110 |
Prophylaxis - adult |
1,047 |
1,047 |
$87K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,124 |
651 |
$75K |
| D0274 |
Bitewings - four radiographic images |
1,767 |
1,766 |
$38K |
| D0230 |
Intraoral - periapical each additional radiographic image |
8,308 |
3,126 |
$33K |
| D4910 |
|
307 |
307 |
$23K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,577 |
1,575 |
$17K |
| D4341 |
|
197 |
70 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
960 |
952 |
$11K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
20 |
18 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
148 |
148 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
119 |
82 |
$6K |
| D0272 |
Bitewings - two radiographic images |
442 |
442 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
20 |
14 |
$2K |
| D1351 |
Sealant - per tooth |
67 |
12 |
$1K |