| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
840 |
840 |
$40K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
476 |
276 |
$32K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
509 |
504 |
$31K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,953 |
1,601 |
$28K |
| D2740 |
Crown - porcelain/ceramic |
38 |
25 |
$18K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
335 |
170 |
$18K |
| D0210 |
Intraoral - complete series of radiographic images |
354 |
350 |
$17K |
| D0350 |
|
1,710 |
735 |
$16K |
| D1120 |
Prophylaxis - child |
390 |
390 |
$14K |
| D0274 |
Bitewings - four radiographic images |
584 |
582 |
$12K |
| D1110 |
Prophylaxis - adult |
68 |
68 |
$6K |
| D0272 |
Bitewings - two radiographic images |
469 |
466 |
$5K |
| D2140 |
|
90 |
41 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
468 |
468 |
$4K |
| D4910 |
|
57 |
57 |
$4K |
| D4341 |
|
53 |
14 |
$4K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
20 |
12 |
$1K |
| D1206 |
Topical application of fluoride varnish |
37 |
37 |
$455.50 |