| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
526 |
524 |
$31K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
366 |
166 |
$29K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,270 |
1,294 |
$22K |
| D0274 |
Bitewings - four radiographic images |
908 |
907 |
$19K |
| D4910 |
|
236 |
236 |
$18K |
| D0350 |
|
1,859 |
598 |
$18K |
| D2740 |
Crown - porcelain/ceramic |
35 |
23 |
$17K |
| D4341 |
|
166 |
45 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
161 |
161 |
$10K |
| D1120 |
Prophylaxis - child |
247 |
246 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
709 |
704 |
$8K |
| D1110 |
Prophylaxis - adult |
66 |
66 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
69 |
43 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
40 |
25 |
$3K |
| D0330 |
Panoramic radiographic image |
16 |
16 |
$480.00 |
| D0220 |
Intraoral - periapical first radiographic image |
14 |
14 |
$168.00 |