| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,573 |
1,571 |
$101K |
| D1120 |
Prophylaxis - child |
1,612 |
1,608 |
$65K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,208 |
542 |
$64K |
| D9430 |
|
1,947 |
1,553 |
$62K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
887 |
887 |
$53K |
| D1110 |
Prophylaxis - adult |
562 |
561 |
$44K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
633 |
334 |
$42K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,176 |
2,172 |
$27K |
| D0210 |
Intraoral - complete series of radiographic images |
531 |
531 |
$24K |
| D0274 |
Bitewings - four radiographic images |
1,061 |
1,061 |
$22K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,420 |
1,460 |
$13K |
| D2740 |
Crown - porcelain/ceramic |
19 |
13 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
262 |
240 |
$3K |
| D0350 |
|
360 |
121 |
$2K |
| D0330 |
Panoramic radiographic image |
45 |
45 |
$1K |
| D1206 |
Topical application of fluoride varnish |
25 |
25 |
$374.00 |