| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,151 |
1,148 |
$79K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
860 |
859 |
$56K |
| D0230 |
Intraoral - periapical each additional radiographic image |
9,091 |
1,781 |
$37K |
| D1120 |
Prophylaxis - child |
825 |
824 |
$36K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
69 |
56 |
$33K |
| D1110 |
Prophylaxis - adult |
288 |
288 |
$25K |
| D0274 |
Bitewings - four radiographic images |
1,050 |
1,047 |
$22K |
| D9430 |
|
530 |
501 |
$17K |
| D0210 |
Intraoral - complete series of radiographic images |
292 |
291 |
$14K |
| D4910 |
|
126 |
126 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
642 |
637 |
$9K |
| D2954 |
|
42 |
31 |
$4K |
| D0350 |
|
328 |
129 |
$3K |
| D1206 |
Topical application of fluoride varnish |
227 |
226 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
41 |
27 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
201 |
198 |
$2K |
| D0272 |
Bitewings - two radiographic images |
150 |
147 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
27 |
13 |
$1K |
| D0330 |
Panoramic radiographic image |
36 |
36 |
$1K |