| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,185 |
2,175 |
$135K |
| D2740 |
Crown - porcelain/ceramic |
193 |
150 |
$92K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,300 |
901 |
$87K |
| D1110 |
Prophylaxis - adult |
904 |
903 |
$77K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,080 |
1,079 |
$69K |
| D1120 |
Prophylaxis - child |
1,548 |
1,545 |
$62K |
| D0210 |
Intraoral - complete series of radiographic images |
1,297 |
1,296 |
$59K |
| D4910 |
|
764 |
762 |
$59K |
| D0230 |
Intraoral - periapical each additional radiographic image |
10,557 |
2,084 |
$44K |
| D0274 |
Bitewings - four radiographic images |
1,744 |
1,736 |
$35K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,484 |
2,478 |
$33K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
542 |
371 |
$29K |
| D4341 |
|
291 |
80 |
$20K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
37 |
26 |
$17K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
228 |
148 |
$15K |
| D0350 |
|
1,171 |
637 |
$11K |
| D2954 |
|
92 |
77 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
49 |
41 |
$4K |
| D2140 |
|
56 |
31 |
$3K |
| D9430 |
|
13 |
13 |
$418.00 |
| D1999 |
|
35 |
32 |
$0.00 |