| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
539 |
535 |
$35K |
| D2332 |
|
384 |
134 |
$31K |
| D4910 |
|
259 |
258 |
$19K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,495 |
852 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
196 |
185 |
$11K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
20 |
15 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
171 |
93 |
$9K |
| D0274 |
Bitewings - four radiographic images |
350 |
349 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
100 |
58 |
$7K |
| D9430 |
|
164 |
159 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
114 |
113 |
$5K |
| D1206 |
Topical application of fluoride varnish |
297 |
296 |
$4K |
| D1120 |
Prophylaxis - child |
52 |
51 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
56 |
55 |
$826.50 |
| D0220 |
Intraoral - periapical first radiographic image |
24 |
24 |
$288.00 |