| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,634 |
1,622 |
$133K |
| D0120 |
Periodic oral evaluation - established patient |
1,547 |
1,535 |
$83K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
1,279 |
333 |
$83K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,116 |
1,111 |
$70K |
| D9110 |
|
869 |
836 |
$54K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,882 |
2,307 |
$49K |
| D0210 |
Intraoral - complete series of radiographic images |
849 |
843 |
$39K |
| D4341 |
|
521 |
138 |
$37K |
| D2140 |
|
644 |
224 |
$34K |
| D1120 |
Prophylaxis - child |
880 |
876 |
$32K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
260 |
132 |
$29K |
| D0220 |
Intraoral - periapical first radiographic image |
1,945 |
1,706 |
$23K |
| D0272 |
Bitewings - two radiographic images |
1,231 |
1,225 |
$14K |
| D4910 |
|
177 |
177 |
$13K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
25 |
20 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
765 |
761 |
$11K |
| D1206 |
Topical application of fluoride varnish |
475 |
471 |
$7K |
| D1320 |
|
415 |
414 |
$6K |
| D9430 |
|
116 |
109 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
70 |
42 |
$4K |
| D2160 |
|
26 |
14 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
26 |
13 |
$2K |
| D2952 |
|
16 |
14 |
$2K |
| D1351 |
Sealant - per tooth |
83 |
16 |
$2K |
| D0274 |
Bitewings - four radiographic images |
43 |
43 |
$864.00 |
| D0330 |
Panoramic radiographic image |
14 |
14 |
$420.00 |