| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
923 |
923 |
$58K |
| D1110 |
Prophylaxis - adult |
544 |
544 |
$49K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
675 |
675 |
$44K |
| D1120 |
Prophylaxis - child |
868 |
862 |
$32K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
51 |
40 |
$24K |
| D0210 |
Intraoral - complete series of radiographic images |
434 |
434 |
$21K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
277 |
171 |
$19K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,839 |
1,071 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
548 |
544 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
495 |
483 |
$6K |
| D0350 |
|
535 |
334 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
66 |
44 |
$5K |
| D2954 |
|
15 |
13 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
23 |
13 |
$1K |
| D9430 |
|
41 |
40 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
24 |
15 |
$1K |
| D0274 |
Bitewings - four radiographic images |
53 |
53 |
$1K |