| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,148 |
2,140 |
$109K |
| D1120 |
Prophylaxis - child |
2,012 |
2,003 |
$69K |
| D0230 |
Intraoral - periapical each additional radiographic image |
11,155 |
1,938 |
$50K |
| D1110 |
Prophylaxis - adult |
491 |
489 |
$43K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,229 |
3,218 |
$36K |
| D0210 |
Intraoral - complete series of radiographic images |
700 |
698 |
$32K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
454 |
454 |
$28K |
| D0272 |
Bitewings - two radiographic images |
1,502 |
1,496 |
$18K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
34 |
12 |
$16K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
274 |
57 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
162 |
44 |
$11K |
| D1351 |
Sealant - per tooth |
413 |
105 |
$10K |
| D4910 |
|
117 |
117 |
$9K |
| D4341 |
|
110 |
31 |
$8K |