| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
3,102 |
3,092 |
$153K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
274 |
198 |
$130K |
| D0230 |
Intraoral - periapical each additional radiographic image |
25,402 |
4,882 |
$110K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,603 |
1,600 |
$98K |
| D1120 |
Prophylaxis - child |
1,954 |
1,949 |
$67K |
| D1110 |
Prophylaxis - adult |
789 |
785 |
$62K |
| D0272 |
Bitewings - two radiographic images |
4,546 |
4,532 |
$53K |
| D7140 |
Extraction, erupted tooth or exposed root |
769 |
368 |
$43K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
569 |
350 |
$38K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
272 |
161 |
$18K |
| D4341 |
|
102 |
46 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
121 |
68 |
$6K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
15 |
14 |
$6K |
| D2954 |
|
58 |
42 |
$6K |
| D1351 |
Sealant - per tooth |
217 |
48 |
$4K |
| D1206 |
Topical application of fluoride varnish |
305 |
304 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
198 |
198 |
$2K |
| D2140 |
|
43 |
29 |
$2K |
| D9430 |
|
57 |
53 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
32 |
32 |
$2K |
| D2330 |
|
18 |
12 |
$1K |
| D0350 |
|
110 |
53 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
121 |
121 |
$1K |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$280.80 |