| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
3,477 |
3,451 |
$190K |
| D1120 |
Prophylaxis - child |
2,514 |
2,495 |
$95K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,356 |
1,346 |
$82K |
| D1110 |
Prophylaxis - adult |
940 |
934 |
$77K |
| D0230 |
Intraoral - periapical each additional radiographic image |
15,006 |
4,927 |
$64K |
| D0274 |
Bitewings - four radiographic images |
3,043 |
3,023 |
$63K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
116 |
85 |
$55K |
| D4341 |
|
764 |
205 |
$52K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,262 |
4,229 |
$51K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
738 |
413 |
$49K |
| D0210 |
Intraoral - complete series of radiographic images |
890 |
885 |
$42K |
| D9430 |
|
1,259 |
1,175 |
$40K |
| D4910 |
|
476 |
473 |
$36K |
| D1351 |
Sealant - per tooth |
1,538 |
391 |
$36K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
278 |
193 |
$31K |
| D0220 |
Intraoral - periapical first radiographic image |
1,661 |
1,622 |
$19K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
363 |
200 |
$19K |
| D1320 |
|
1,089 |
1,087 |
$16K |
| D0350 |
|
1,195 |
421 |
$11K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
127 |
68 |
$8K |
| D2952 |
|
56 |
42 |
$6K |
| D0272 |
Bitewings - two radiographic images |
414 |
410 |
$5K |
| D1330 |
|
47 |
47 |
$0.00 |