| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
773 |
767 |
$38K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
486 |
483 |
$27K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,618 |
937 |
$19K |
| D0210 |
Intraoral - complete series of radiographic images |
408 |
407 |
$18K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
37 |
28 |
$18K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
264 |
125 |
$17K |
| D4910 |
|
181 |
181 |
$14K |
| D0274 |
Bitewings - four radiographic images |
672 |
666 |
$13K |
| D1110 |
Prophylaxis - adult |
148 |
148 |
$9K |
| D9430 |
|
278 |
234 |
$9K |
| D4341 |
|
119 |
38 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
154 |
82 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
517 |
514 |
$5K |
| D1120 |
Prophylaxis - child |
53 |
53 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
50 |
47 |
$516.00 |
| D1999 |
|
74 |
74 |
$0.00 |