| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,732 |
2,722 |
$151K |
| D1110 |
Prophylaxis - adult |
1,336 |
1,328 |
$111K |
| D1120 |
Prophylaxis - child |
1,851 |
1,846 |
$72K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
888 |
888 |
$55K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
738 |
481 |
$48K |
| D0274 |
Bitewings - four radiographic images |
2,107 |
2,102 |
$43K |
| D0210 |
Intraoral - complete series of radiographic images |
710 |
709 |
$32K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,023 |
2,901 |
$24K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,779 |
1,774 |
$19K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
15 |
13 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
121 |
86 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
78 |
42 |
$4K |
| D0350 |
|
313 |
219 |
$3K |
| D4910 |
|
36 |
36 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
25 |
14 |
$2K |
| D9430 |
|
24 |
24 |
$720.00 |
| D0272 |
Bitewings - two radiographic images |
25 |
25 |
$276.00 |
| D1206 |
Topical application of fluoride varnish |
26 |
26 |
$210.00 |
| D0220 |
Intraoral - periapical first radiographic image |
15 |
15 |
$150.00 |