| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,235 |
2,232 |
$125K |
| D1110 |
Prophylaxis - adult |
1,128 |
1,126 |
$98K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,110 |
1,104 |
$70K |
| D9430 |
|
2,014 |
1,779 |
$64K |
| D1120 |
Prophylaxis - child |
1,668 |
1,665 |
$64K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,921 |
2,917 |
$41K |
| D0274 |
Bitewings - four radiographic images |
1,887 |
1,885 |
$40K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,830 |
2,819 |
$27K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
49 |
39 |
$23K |
| D0350 |
|
1,268 |
876 |
$20K |
| D0210 |
Intraoral - complete series of radiographic images |
337 |
334 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
988 |
974 |
$12K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
138 |
66 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
75 |
51 |
$4K |
| D4341 |
|
43 |
13 |
$3K |
| D2140 |
|
18 |
12 |
$982.80 |
| D0272 |
Bitewings - two radiographic images |
61 |
61 |
$668.00 |
| D1999 |
|
21 |
21 |
$30.00 |