| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
4,749 |
4,729 |
$222K |
| D1120 |
Prophylaxis - child |
3,360 |
3,349 |
$125K |
| D1110 |
Prophylaxis - adult |
1,167 |
1,164 |
$103K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,654 |
1,646 |
$103K |
| D4910 |
|
1,294 |
1,292 |
$98K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
1,393 |
921 |
$92K |
| D0210 |
Intraoral - complete series of radiographic images |
1,951 |
1,942 |
$89K |
| D0230 |
Intraoral - periapical each additional radiographic image |
18,546 |
4,036 |
$74K |
| D4341 |
|
1,000 |
332 |
$70K |
| D0274 |
Bitewings - four radiographic images |
2,529 |
2,520 |
$53K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,016 |
3,999 |
$46K |
| D2140 |
|
765 |
534 |
$41K |
| D1351 |
Sealant - per tooth |
1,029 |
306 |
$22K |
| D9430 |
|
664 |
652 |
$21K |
| D0272 |
Bitewings - two radiographic images |
1,218 |
1,211 |
$14K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
25 |
18 |
$12K |
| D7140 |
Extraction, erupted tooth or exposed root |
100 |
53 |
$6K |
| D2330 |
|
20 |
14 |
$2K |
| D2160 |
|
13 |
13 |
$1K |
| D4342 |
|
22 |
12 |
$924.00 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$144.00 |
| D0270 |
|
12 |
12 |
$60.00 |