| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,381 |
2,369 |
$136K |
| D1120 |
Prophylaxis - child |
2,500 |
2,487 |
$98K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
161 |
103 |
$77K |
| D0230 |
Intraoral - periapical each additional radiographic image |
17,494 |
3,187 |
$71K |
| D0274 |
Bitewings - four radiographic images |
1,834 |
1,824 |
$39K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,060 |
3,046 |
$38K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
575 |
575 |
$38K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
321 |
163 |
$22K |
| D0210 |
Intraoral - complete series of radiographic images |
313 |
313 |
$15K |
| D1110 |
Prophylaxis - adult |
105 |
105 |
$9K |
| D1351 |
Sealant - per tooth |
239 |
66 |
$6K |
| D0272 |
Bitewings - two radiographic images |
254 |
254 |
$3K |
| D0330 |
Panoramic radiographic image |
77 |
77 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
37 |
12 |
$2K |
| D4910 |
|
16 |
16 |
$1K |