| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,757 |
1,742 |
$99K |
| D1120 |
Prophylaxis - child |
1,604 |
1,591 |
$60K |
| D0230 |
Intraoral - periapical each additional radiographic image |
9,935 |
2,075 |
$43K |
| D4910 |
|
380 |
373 |
$29K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,105 |
2,083 |
$26K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
56 |
34 |
$26K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
282 |
282 |
$17K |
| D0274 |
Bitewings - four radiographic images |
691 |
688 |
$15K |
| D1351 |
Sealant - per tooth |
375 |
104 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
881 |
865 |
$10K |
| D0350 |
|
488 |
230 |
$4K |
| D1320 |
|
196 |
192 |
$3K |
| D9430 |
|
60 |
58 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
20 |
12 |
$1K |
| D0272 |
Bitewings - two radiographic images |
38 |
38 |
$456.00 |