| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,279 |
2,271 |
$127K |
| D1110 |
Prophylaxis - adult |
926 |
924 |
$79K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,001 |
569 |
$66K |
| D1120 |
Prophylaxis - child |
1,672 |
1,667 |
$62K |
| D0350 |
|
4,759 |
2,077 |
$43K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,927 |
2,920 |
$36K |
| D0274 |
Bitewings - four radiographic images |
1,739 |
1,736 |
$33K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,530 |
2,557 |
$26K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
477 |
239 |
$26K |
| D0210 |
Intraoral - complete series of radiographic images |
541 |
541 |
$25K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
401 |
401 |
$25K |
| D0220 |
Intraoral - periapical first radiographic image |
1,464 |
1,334 |
$17K |
| D9430 |
|
441 |
398 |
$14K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
15 |
12 |
$7K |
| D0330 |
Panoramic radiographic image |
50 |
50 |
$1K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
16 |
13 |
$1K |
| D0272 |
Bitewings - two radiographic images |
58 |
58 |
$668.00 |