| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
5,347 |
5,341 |
$298K |
| D1120 |
Prophylaxis - child |
5,494 |
5,484 |
$212K |
| D0230 |
Intraoral - periapical each additional radiographic image |
38,214 |
6,931 |
$156K |
| D1110 |
Prophylaxis - adult |
1,359 |
1,359 |
$116K |
| D1351 |
Sealant - per tooth |
4,066 |
1,068 |
$110K |
| D0274 |
Bitewings - four radiographic images |
4,591 |
4,589 |
$97K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,449 |
1,448 |
$92K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
182 |
112 |
$86K |
| D4910 |
|
1,038 |
1,038 |
$79K |
| D1206 |
Topical application of fluoride varnish |
5,328 |
5,322 |
$68K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
814 |
322 |
$54K |
| D1310 |
|
1,168 |
1,161 |
$53K |
| D7140 |
Extraction, erupted tooth or exposed root |
600 |
309 |
$34K |
| D9993 |
|
1,150 |
1,144 |
$34K |
| D0350 |
|
3,493 |
1,130 |
$32K |
| D9430 |
|
968 |
934 |
$31K |
| D4341 |
|
394 |
133 |
$28K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
420 |
177 |
$23K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,384 |
1,384 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
1,649 |
1,587 |
$19K |
| D0603 |
|
1,062 |
1,057 |
$16K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
188 |
78 |
$13K |
| D2954 |
|
118 |
82 |
$12K |
| D0272 |
Bitewings - two radiographic images |
940 |
939 |
$11K |
| D1320 |
|
694 |
694 |
$10K |
| D2140 |
|
62 |
27 |
$3K |