| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,016 |
2,010 |
$116K |
| D1110 |
Prophylaxis - adult |
1,143 |
1,133 |
$97K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,335 |
1,329 |
$84K |
| D1120 |
Prophylaxis - child |
1,819 |
1,807 |
$72K |
| D0230 |
Intraoral - periapical each additional radiographic image |
12,872 |
2,578 |
$49K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,038 |
3,018 |
$40K |
| D0210 |
Intraoral - complete series of radiographic images |
529 |
529 |
$24K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
29 |
26 |
$14K |
| D0274 |
Bitewings - four radiographic images |
683 |
682 |
$13K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
178 |
108 |
$12K |
| D0272 |
Bitewings - two radiographic images |
678 |
677 |
$8K |
| D0350 |
|
617 |
283 |
$6K |
| D2140 |
|
65 |
38 |
$3K |
| D0250 |
|
159 |
141 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
298 |
295 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
52 |
25 |
$3K |
| D1351 |
Sealant - per tooth |
78 |
15 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
27 |
15 |
$2K |
| D9110 |
|
13 |
12 |
$756.00 |
| D0260 |
|
39 |
28 |
$215.00 |
| D1330 |
|
1,122 |
1,119 |
$0.00 |
| D1999 |
|
20 |
20 |
$0.00 |