| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,302 |
2,299 |
$62K |
| D0120 |
Periodic oral evaluation - established patient |
2,575 |
2,573 |
$61K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
785 |
578 |
$45K |
| D0210 |
Intraoral - complete series of radiographic images |
1,197 |
1,197 |
$44K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
89 |
87 |
$38K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
976 |
975 |
$33K |
| D1351 |
Sealant - per tooth |
1,498 |
227 |
$21K |
| D0274 |
Bitewings - four radiographic images |
1,312 |
1,311 |
$18K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,194 |
1,193 |
$18K |
| D1120 |
Prophylaxis - child |
693 |
692 |
$15K |
| D0140 |
Limited oral evaluation - problem focused |
990 |
979 |
$9K |
| D2140 |
|
170 |
138 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
1,393 |
1,352 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
119 |
74 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
606 |
590 |
$4K |
| D2160 |
|
52 |
49 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
52 |
40 |
$3K |
| D2950 |
|
40 |
36 |
$3K |
| D0602 |
|
212 |
211 |
$2K |
| D0603 |
|
96 |
96 |
$960.00 |
| D9110 |
|
55 |
53 |
$669.00 |