| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,136 |
1,129 |
$74K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,084 |
1,076 |
$70K |
| D1110 |
Prophylaxis - adult |
606 |
602 |
$51K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
643 |
240 |
$50K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
104 |
87 |
$49K |
| D1120 |
Prophylaxis - child |
987 |
979 |
$41K |
| D0210 |
Intraoral - complete series of radiographic images |
756 |
755 |
$36K |
| D9920 |
|
290 |
274 |
$29K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,021 |
2,004 |
$26K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
279 |
123 |
$18K |
| D9430 |
|
532 |
510 |
$17K |
| D4910 |
|
185 |
181 |
$13K |
| D2954 |
|
116 |
98 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,487 |
1,330 |
$10K |
| D0274 |
Bitewings - four radiographic images |
464 |
457 |
$10K |
| D1320 |
|
569 |
568 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
621 |
603 |
$7K |
| D4341 |
|
93 |
25 |
$7K |
| D9410 |
|
69 |
69 |
$1K |
| D0350 |
|
48 |
26 |
$566.40 |
| D1206 |
Topical application of fluoride varnish |
21 |
21 |
$324.00 |
| D0272 |
Bitewings - two radiographic images |
25 |
25 |
$300.00 |
| D1999 |
|
395 |
367 |
$227.00 |
| D1310 |
|
1,780 |
1,767 |
$99.00 |
| D1330 |
|
1,831 |
1,817 |
$0.00 |