| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,297 |
1,229 |
$36K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
61 |
32 |
$32K |
| D1110 |
Prophylaxis - adult |
612 |
568 |
$26K |
| D1120 |
Prophylaxis - child |
527 |
516 |
$23K |
| D1206 |
Topical application of fluoride varnish |
431 |
431 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
465 |
438 |
$11K |
| D1351 |
Sealant - per tooth |
400 |
66 |
$8K |
| D0274 |
Bitewings - four radiographic images |
565 |
540 |
$6K |
| D0330 |
Panoramic radiographic image |
176 |
145 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
1,045 |
936 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
96 |
96 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
366 |
357 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
480 |
433 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
41 |
41 |
$2K |
| D0350 |
|
12 |
12 |
$2K |
| D0272 |
Bitewings - two radiographic images |
131 |
131 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
18 |
12 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
22 |
12 |
$1K |