| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
879 |
878 |
$58K |
| D0120 |
Periodic oral evaluation - established patient |
440 |
439 |
$36K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
639 |
374 |
$35K |
| D0350 |
|
2,968 |
1,132 |
$29K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
59 |
49 |
$28K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
394 |
251 |
$26K |
| D0210 |
Intraoral - complete series of radiographic images |
545 |
545 |
$26K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,262 |
1,104 |
$22K |
| D1120 |
Prophylaxis - child |
384 |
383 |
$17K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,013 |
1,009 |
$14K |
| D9430 |
|
339 |
325 |
$11K |
| D0274 |
Bitewings - four radiographic images |
359 |
359 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
499 |
493 |
$6K |
| D1110 |
Prophylaxis - adult |
58 |
58 |
$5K |
| D4341 |
|
22 |
12 |
$2K |