| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,134 |
1,133 |
$71K |
| D4910 |
|
736 |
734 |
$56K |
| D1110 |
Prophylaxis - adult |
470 |
469 |
$41K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
639 |
639 |
$40K |
| D0210 |
Intraoral - complete series of radiographic images |
705 |
703 |
$33K |
| D0330 |
Panoramic radiographic image |
793 |
790 |
$24K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
297 |
151 |
$20K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,351 |
1,349 |
$19K |
| D0274 |
Bitewings - four radiographic images |
758 |
757 |
$15K |
| D1120 |
Prophylaxis - child |
326 |
326 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,298 |
1,037 |
$9K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
15 |
14 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
56 |
40 |
$3K |
| D2954 |
|
13 |
12 |
$1K |
| D1320 |
|
31 |
31 |
$542.50 |
| D0350 |
|
20 |
13 |
$192.00 |
| D1206 |
Topical application of fluoride varnish |
25 |
24 |
$142.00 |