| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,312 |
1,312 |
$86K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,049 |
556 |
$70K |
| D0120 |
Periodic oral evaluation - established patient |
855 |
853 |
$61K |
| D0210 |
Intraoral - complete series of radiographic images |
1,024 |
1,024 |
$49K |
| D1110 |
Prophylaxis - adult |
454 |
454 |
$41K |
| D1120 |
Prophylaxis - child |
764 |
763 |
$35K |
| D9430 |
|
752 |
669 |
$24K |
| D2740 |
Crown - porcelain/ceramic |
42 |
25 |
$20K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
332 |
191 |
$18K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,437 |
1,074 |
$18K |
| D1208 |
Topical application of fluoride, excluding varnish |
938 |
935 |
$14K |
| D0274 |
Bitewings - four radiographic images |
635 |
635 |
$13K |
| D0350 |
|
1,061 |
481 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
107 |
70 |
$8K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
13 |
12 |
$6K |
| D4910 |
|
68 |
68 |
$5K |
| D4341 |
|
50 |
14 |
$4K |
| D1206 |
Topical application of fluoride varnish |
190 |
190 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
85 |
85 |
$1K |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$144.00 |