| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
638 |
624 |
$39K |
| D1120 |
Prophylaxis - child |
452 |
446 |
$19K |
| D1110 |
Prophylaxis - adult |
229 |
213 |
$18K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
218 |
115 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
240 |
232 |
$16K |
| D2740 |
Crown - porcelain/ceramic |
38 |
14 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
423 |
406 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
166 |
156 |
$7K |
| D2140 |
|
47 |
31 |
$3K |
| D1351 |
Sealant - per tooth |
164 |
26 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
451 |
223 |
$2K |
| D1206 |
Topical application of fluoride varnish |
350 |
348 |
$1K |
| D0274 |
Bitewings - four radiographic images |
90 |
89 |
$933.15 |
| D0272 |
Bitewings - two radiographic images |
27 |
27 |
$350.38 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$319.59 |