| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,263 |
2,258 |
$128K |
| D1110 |
Prophylaxis - adult |
1,086 |
1,082 |
$95K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
176 |
133 |
$84K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,119 |
1,115 |
$70K |
| D1120 |
Prophylaxis - child |
822 |
821 |
$31K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,261 |
2,256 |
$30K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,150 |
1,141 |
$29K |
| D4341 |
|
454 |
126 |
$27K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
313 |
151 |
$21K |
| D0210 |
Intraoral - complete series of radiographic images |
425 |
422 |
$20K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
241 |
113 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
959 |
952 |
$11K |
| D2954 |
|
17 |
14 |
$2K |
| D4910 |
|
13 |
13 |
$1K |
| D0272 |
Bitewings - two radiographic images |
79 |
79 |
$844.00 |
| D9430 |
|
18 |
17 |
$576.00 |
| D0350 |
|
33 |
13 |
$316.80 |