| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,310 |
2,304 |
$190K |
| D0120 |
Periodic oral evaluation - established patient |
3,470 |
3,465 |
$182K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,653 |
1,652 |
$99K |
| D0230 |
Intraoral - periapical each additional radiographic image |
23,366 |
4,107 |
$95K |
| D1120 |
Prophylaxis - child |
2,493 |
2,489 |
$91K |
| D0210 |
Intraoral - complete series of radiographic images |
1,958 |
1,956 |
$91K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
1,286 |
889 |
$85K |
| D2140 |
|
1,005 |
630 |
$53K |
| D0274 |
Bitewings - four radiographic images |
2,319 |
2,313 |
$48K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,214 |
3,211 |
$35K |
| D1351 |
Sealant - per tooth |
1,276 |
384 |
$30K |
| D7140 |
Extraction, erupted tooth or exposed root |
517 |
310 |
$29K |
| D1206 |
Topical application of fluoride varnish |
1,549 |
1,541 |
$25K |
| D0350 |
|
2,523 |
1,501 |
$24K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
103 |
79 |
$12K |
| D2160 |
|
119 |
97 |
$9K |
| D2740 |
Crown - porcelain/ceramic |
17 |
14 |
$8K |
| D0272 |
Bitewings - two radiographic images |
637 |
637 |
$7K |
| D4341 |
|
118 |
33 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
517 |
507 |
$6K |
| D9430 |
|
177 |
173 |
$5K |
| D2931 |
|
15 |
14 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
24 |
12 |
$1K |
| D2330 |
|
18 |
12 |
$1K |
| D4910 |
|
12 |
12 |
$924.00 |