| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
829 |
823 |
$56K |
| D1110 |
Prophylaxis - adult |
626 |
625 |
$55K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
646 |
646 |
$42K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,180 |
928 |
$21K |
| D0210 |
Intraoral - complete series of radiographic images |
425 |
424 |
$20K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,352 |
1,340 |
$18K |
| D1120 |
Prophylaxis - child |
412 |
411 |
$17K |
| D0274 |
Bitewings - four radiographic images |
727 |
727 |
$14K |
| D9430 |
|
295 |
288 |
$9K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
19 |
13 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
256 |
252 |
$3K |
| D1351 |
Sealant - per tooth |
139 |
28 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
19 |
14 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
19 |
13 |
$1K |
| D0350 |
|
78 |
42 |
$672.00 |