| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,482 |
1,468 |
$90K |
| D1110 |
Prophylaxis - adult |
575 |
572 |
$45K |
| D0120 |
Periodic oral evaluation - established patient |
755 |
747 |
$43K |
| D1206 |
Topical application of fluoride varnish |
1,572 |
1,560 |
$26K |
| D1120 |
Prophylaxis - child |
583 |
579 |
$22K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,403 |
1,765 |
$20K |
| D0210 |
Intraoral - complete series of radiographic images |
395 |
388 |
$15K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
29 |
25 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
198 |
119 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
881 |
872 |
$9K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
100 |
56 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
119 |
64 |
$6K |
| D0272 |
Bitewings - two radiographic images |
526 |
519 |
$6K |
| D9430 |
|
136 |
132 |
$4K |
| D4341 |
|
52 |
13 |
$3K |
| D2954 |
|
19 |
14 |
$2K |
| D2952 |
|
19 |
12 |
$2K |
| D0274 |
Bitewings - four radiographic images |
62 |
62 |
$1K |
| D0330 |
Panoramic radiographic image |
25 |
25 |
$705.00 |