| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,049 |
2,046 |
$113K |
| D1120 |
Prophylaxis - child |
1,650 |
1,650 |
$61K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
735 |
735 |
$46K |
| D1110 |
Prophylaxis - adult |
451 |
451 |
$39K |
| D0230 |
Intraoral - periapical each additional radiographic image |
8,141 |
2,097 |
$32K |
| D0274 |
Bitewings - four radiographic images |
1,257 |
1,257 |
$26K |
| D2740 |
Crown - porcelain/ceramic |
24 |
14 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
165 |
106 |
$11K |
| D0210 |
Intraoral - complete series of radiographic images |
117 |
117 |
$5K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
54 |
29 |
$4K |
| D4341 |
|
49 |
13 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
204 |
204 |
$2K |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$144.00 |
| D0350 |
|
15 |
12 |
$144.00 |