| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,180 |
1,176 |
$62K |
| D1110 |
Prophylaxis - adult |
520 |
516 |
$45K |
| D1120 |
Prophylaxis - child |
752 |
751 |
$28K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
378 |
376 |
$24K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
432 |
171 |
$23K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
48 |
44 |
$23K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,389 |
1,718 |
$21K |
| D0274 |
Bitewings - four radiographic images |
816 |
815 |
$17K |
| D0210 |
Intraoral - complete series of radiographic images |
313 |
312 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
203 |
110 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
666 |
665 |
$7K |
| D9430 |
|
207 |
184 |
$6K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
12 |
12 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
430 |
400 |
$5K |
| D2954 |
|
33 |
30 |
$3K |
| D4341 |
|
36 |
14 |
$3K |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$138.00 |