| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,452 |
2,446 |
$140K |
| D1110 |
Prophylaxis - adult |
1,182 |
1,173 |
$103K |
| D1120 |
Prophylaxis - child |
2,326 |
2,323 |
$90K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
1,316 |
581 |
$88K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,098 |
1,087 |
$70K |
| D0230 |
Intraoral - periapical each additional radiographic image |
8,196 |
3,020 |
$63K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,716 |
3,704 |
$48K |
| D0210 |
Intraoral - complete series of radiographic images |
825 |
825 |
$38K |
| D9430 |
|
1,042 |
1,023 |
$33K |
| D0274 |
Bitewings - four radiographic images |
1,400 |
1,393 |
$30K |
| D2160 |
|
336 |
186 |
$27K |
| D1351 |
Sealant - per tooth |
838 |
207 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
1,520 |
1,411 |
$18K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
17 |
12 |
$8K |
| D0272 |
Bitewings - two radiographic images |
662 |
662 |
$8K |
| D4341 |
|
54 |
14 |
$4K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
14 |
12 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
28 |
12 |
$2K |
| D2140 |
|
16 |
12 |
$873.60 |
| D0350 |
|
19 |
15 |
$393.60 |