| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
6,317 |
6,293 |
$347K |
| D1120 |
Prophylaxis - child |
7,271 |
7,245 |
$285K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
3,273 |
1,435 |
$219K |
| D0274 |
Bitewings - four radiographic images |
5,640 |
5,619 |
$117K |
| D1208 |
Topical application of fluoride, excluding varnish |
7,203 |
7,177 |
$77K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,172 |
1,170 |
$73K |
| D0230 |
Intraoral - periapical each additional radiographic image |
15,177 |
6,587 |
$61K |
| D2160 |
|
716 |
408 |
$57K |
| D0210 |
Intraoral - complete series of radiographic images |
819 |
813 |
$38K |
| D2740 |
Crown - porcelain/ceramic |
69 |
45 |
$32K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
48 |
46 |
$22K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
33 |
29 |
$15K |
| D3221 |
|
145 |
124 |
$9K |
| D2954 |
|
83 |
63 |
$8K |
| D0272 |
Bitewings - two radiographic images |
525 |
525 |
$6K |
| D2940 |
|
72 |
56 |
$4K |
| D1351 |
Sealant - per tooth |
68 |
12 |
$1K |
| D2140 |
|
15 |
12 |
$764.40 |