| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
882 |
879 |
$58K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
92 |
58 |
$44K |
| D1120 |
Prophylaxis - child |
864 |
855 |
$31K |
| D0120 |
Periodic oral evaluation - established patient |
432 |
424 |
$29K |
| D1351 |
Sealant - per tooth |
942 |
191 |
$21K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,736 |
781 |
$15K |
| D0330 |
Panoramic radiographic image |
516 |
514 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
204 |
54 |
$14K |
| D1110 |
Prophylaxis - adult |
156 |
156 |
$14K |
| D0210 |
Intraoral - complete series of radiographic images |
175 |
172 |
$8K |
| D2954 |
|
68 |
55 |
$7K |
| D1206 |
Topical application of fluoride varnish |
671 |
671 |
$7K |
| D4341 |
|
66 |
25 |
$5K |
| D0274 |
Bitewings - four radiographic images |
180 |
173 |
$3K |
| D9430 |
|
105 |
104 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
215 |
205 |
$3K |
| D0272 |
Bitewings - two radiographic images |
236 |
236 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
138 |
134 |
$2K |
| D0350 |
|
112 |
30 |
$1K |