| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
735 |
729 |
$49K |
| D0120 |
Periodic oral evaluation - established patient |
337 |
333 |
$24K |
| D0210 |
Intraoral - complete series of radiographic images |
472 |
466 |
$23K |
| D9430 |
|
423 |
386 |
$14K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
25 |
13 |
$12K |
| D2740 |
Crown - porcelain/ceramic |
24 |
12 |
$11K |
| D1110 |
Prophylaxis - adult |
84 |
84 |
$7K |
| D1120 |
Prophylaxis - child |
122 |
120 |
$6K |
| D0274 |
Bitewings - four radiographic images |
263 |
263 |
$5K |
| D2954 |
|
50 |
29 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
98 |
45 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
339 |
339 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
55 |
27 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
815 |
291 |
$3K |
| D0350 |
|
241 |
89 |
$2K |
| D0330 |
Panoramic radiographic image |
42 |
42 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
102 |
97 |
$1K |
| D4910 |
|
14 |
14 |
$1K |