| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,400 |
1,388 |
$81K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
899 |
464 |
$60K |
| D1120 |
Prophylaxis - child |
1,100 |
1,093 |
$41K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
673 |
673 |
$41K |
| D0274 |
Bitewings - four radiographic images |
1,362 |
1,349 |
$29K |
| D1110 |
Prophylaxis - adult |
273 |
266 |
$24K |
| D0210 |
Intraoral - complete series of radiographic images |
521 |
521 |
$24K |
| D9430 |
|
728 |
703 |
$23K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,502 |
1,490 |
$17K |
| D2740 |
Crown - porcelain/ceramic |
32 |
25 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,428 |
1,825 |
$14K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
33 |
25 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
21 |
12 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
79 |
78 |
$948.00 |
| D0330 |
Panoramic radiographic image |
13 |
12 |
$330.00 |