| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,781 |
2,774 |
$144K |
| D1120 |
Prophylaxis - child |
2,363 |
2,361 |
$80K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
647 |
647 |
$38K |
| D0274 |
Bitewings - four radiographic images |
1,700 |
1,699 |
$35K |
| D0210 |
Intraoral - complete series of radiographic images |
542 |
542 |
$25K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,057 |
2,919 |
$24K |
| D1206 |
Topical application of fluoride varnish |
2,345 |
2,341 |
$24K |
| D0350 |
|
1,839 |
794 |
$18K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
233 |
115 |
$16K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
277 |
142 |
$15K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
19 |
12 |
$9K |
| D1110 |
Prophylaxis - adult |
97 |
97 |
$9K |
| D0272 |
Bitewings - two radiographic images |
311 |
310 |
$4K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
29 |
14 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
48 |
48 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
116 |
116 |
$2K |
| D1351 |
Sealant - per tooth |
52 |
12 |
$1K |
| D0330 |
Panoramic radiographic image |
19 |
19 |
$570.00 |