| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
3,266 |
3,241 |
$159K |
| D1110 |
Prophylaxis - adult |
1,893 |
1,881 |
$149K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,711 |
1,703 |
$100K |
| D1120 |
Prophylaxis - child |
2,751 |
2,724 |
$99K |
| D0210 |
Intraoral - complete series of radiographic images |
1,656 |
1,643 |
$71K |
| D9430 |
|
1,206 |
1,162 |
$37K |
| D0274 |
Bitewings - four radiographic images |
1,425 |
1,417 |
$30K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,420 |
2,549 |
$29K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
60 |
50 |
$29K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,130 |
2,116 |
$23K |
| D4341 |
|
307 |
127 |
$21K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
327 |
232 |
$21K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
45 |
32 |
$17K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
123 |
68 |
$14K |
| D1351 |
Sealant - per tooth |
567 |
122 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
939 |
911 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
146 |
114 |
$8K |
| D4910 |
|
74 |
74 |
$6K |
| D2952 |
|
52 |
43 |
$5K |
| D0340 |
|
65 |
64 |
$3K |
| D0330 |
Panoramic radiographic image |
91 |
91 |
$3K |
| D1206 |
Topical application of fluoride varnish |
278 |
272 |
$2K |
| D0272 |
Bitewings - two radiographic images |
189 |
187 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
14 |
14 |
$455.00 |