| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
348 |
348 |
$23K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,125 |
1,092 |
$20K |
| D0350 |
|
1,565 |
691 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
204 |
204 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
222 |
130 |
$12K |
| D1120 |
Prophylaxis - child |
256 |
256 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
107 |
79 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
491 |
491 |
$7K |
| D0274 |
Bitewings - four radiographic images |
321 |
321 |
$6K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
13 |
12 |
$6K |
| D9430 |
|
182 |
182 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
112 |
112 |
$5K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
48 |
27 |
$3K |
| D2140 |
|
52 |
26 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
222 |
220 |
$2K |
| D4341 |
|
24 |
12 |
$2K |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$1K |