| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,511 |
1,497 |
$126K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,280 |
1,272 |
$80K |
| D0120 |
Periodic oral evaluation - established patient |
1,410 |
1,406 |
$73K |
| D0210 |
Intraoral - complete series of radiographic images |
1,301 |
1,291 |
$60K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,769 |
2,749 |
$35K |
| D1120 |
Prophylaxis - child |
924 |
920 |
$32K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,312 |
1,296 |
$30K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
53 |
32 |
$25K |
| D9430 |
|
726 |
688 |
$23K |
| D0220 |
Intraoral - periapical first radiographic image |
1,161 |
1,102 |
$14K |
| D0274 |
Bitewings - four radiographic images |
544 |
543 |
$11K |
| D2140 |
|
97 |
55 |
$5K |
| D1351 |
Sealant - per tooth |
182 |
39 |
$4K |
| D4341 |
|
47 |
15 |
$3K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
27 |
24 |
$3K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
44 |
28 |
$3K |
| D2954 |
|
14 |
12 |
$1K |
| D0272 |
Bitewings - two radiographic images |
107 |
107 |
$1K |