| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,294 |
2,283 |
$122K |
| D1110 |
Prophylaxis - adult |
1,283 |
1,273 |
$108K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,418 |
1,016 |
$94K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,731 |
1,065 |
$93K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,343 |
1,334 |
$84K |
| D1120 |
Prophylaxis - child |
1,789 |
1,785 |
$66K |
| D0274 |
Bitewings - four radiographic images |
2,721 |
2,706 |
$56K |
| D0230 |
Intraoral - periapical each additional radiographic image |
11,996 |
4,179 |
$49K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,509 |
2,499 |
$28K |
| D9430 |
|
835 |
810 |
$26K |
| D7140 |
Extraction, erupted tooth or exposed root |
403 |
236 |
$23K |
| D1206 |
Topical application of fluoride varnish |
554 |
553 |
$9K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
14 |
12 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
75 |
75 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
262 |
258 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
29 |
25 |
$2K |
| D0272 |
Bitewings - two radiographic images |
28 |
28 |
$324.00 |