| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,772 |
1,762 |
$92K |
| D1120 |
Prophylaxis - child |
1,363 |
1,356 |
$48K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
101 |
68 |
$48K |
| D1110 |
Prophylaxis - adult |
553 |
553 |
$45K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,189 |
2,210 |
$38K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
568 |
565 |
$32K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
445 |
247 |
$28K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
231 |
108 |
$15K |
| D0272 |
Bitewings - two radiographic images |
1,266 |
1,255 |
$15K |
| D0210 |
Intraoral - complete series of radiographic images |
344 |
344 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,093 |
1,087 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
153 |
64 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
528 |
499 |
$6K |
| D0350 |
|
288 |
239 |
$5K |
| D2952 |
|
40 |
27 |
$4K |
| D0274 |
Bitewings - four radiographic images |
219 |
218 |
$4K |
| D1206 |
Topical application of fluoride varnish |
349 |
347 |
$4K |
| D4341 |
|
56 |
16 |
$4K |
| D2160 |
|
42 |
25 |
$3K |
| D1351 |
Sealant - per tooth |
149 |
39 |
$3K |
| D9430 |
|
85 |
83 |
$3K |
| D9999 |
Unspecified adjunctive procedure, by report |
12 |
12 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
16 |
12 |
$1K |
| D1999 |
|
60 |
57 |
$0.00 |