| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
3,913 |
3,876 |
$209K |
| D1110 |
Prophylaxis - adult |
1,838 |
1,820 |
$157K |
| D1120 |
Prophylaxis - child |
2,750 |
2,723 |
$101K |
| D0230 |
Intraoral - periapical each additional radiographic image |
18,854 |
5,151 |
$79K |
| D0220 |
Intraoral - periapical first radiographic image |
5,855 |
5,760 |
$69K |
| D1206 |
Topical application of fluoride varnish |
3,398 |
3,361 |
$49K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
674 |
667 |
$42K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,277 |
1,270 |
$13K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
19 |
12 |
$9K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
41 |
25 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
82 |
54 |
$5K |
| D2160 |
|
55 |
40 |
$4K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
40 |
27 |
$3K |