| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
3,653 |
3,639 |
$201K |
| D1110 |
Prophylaxis - adult |
2,121 |
2,106 |
$174K |
| D1120 |
Prophylaxis - child |
3,292 |
3,275 |
$126K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,037 |
2,033 |
$125K |
| D1208 |
Topical application of fluoride, excluding varnish |
5,635 |
5,612 |
$75K |
| D0210 |
Intraoral - complete series of radiographic images |
1,534 |
1,531 |
$71K |
| D1351 |
Sealant - per tooth |
2,337 |
548 |
$66K |
| D2740 |
Crown - porcelain/ceramic |
106 |
80 |
$50K |
| D0230 |
Intraoral - periapical each additional radiographic image |
10,810 |
2,950 |
$44K |
| D0350 |
|
4,506 |
2,032 |
$42K |
| D0274 |
Bitewings - four radiographic images |
1,797 |
1,788 |
$37K |
| D4910 |
|
483 |
481 |
$36K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
512 |
305 |
$33K |
| D0220 |
Intraoral - periapical first radiographic image |
2,672 |
2,612 |
$30K |
| D4341 |
|
382 |
133 |
$26K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
474 |
256 |
$25K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
160 |
98 |
$19K |
| D2140 |
|
262 |
139 |
$14K |
| D9110 |
|
38 |
38 |
$2K |
| D0272 |
Bitewings - two radiographic images |
128 |
128 |
$1K |
| D2330 |
|
16 |
12 |
$1K |
| D9430 |
|
13 |
13 |
$364.00 |