| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
964 |
962 |
$59K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
658 |
658 |
$39K |
| D1110 |
Prophylaxis - adult |
417 |
417 |
$35K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
66 |
40 |
$31K |
| D0210 |
Intraoral - complete series of radiographic images |
635 |
634 |
$29K |
| D4910 |
|
358 |
358 |
$27K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,574 |
1,288 |
$27K |
| D1120 |
Prophylaxis - child |
649 |
648 |
$24K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,718 |
1,717 |
$21K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
265 |
141 |
$17K |
| D0272 |
Bitewings - two radiographic images |
586 |
584 |
$7K |
| D2140 |
|
115 |
66 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
73 |
41 |
$4K |
| D1351 |
Sealant - per tooth |
113 |
27 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
108 |
108 |
$1K |
| D9430 |
|
27 |
27 |
$780.00 |
| D0330 |
Panoramic radiographic image |
30 |
30 |
$664.50 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$259.20 |
| D0350 |
|
33 |
16 |
$240.00 |
| D1999 |
|
19 |
16 |
$0.00 |