| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,978 |
2,970 |
$167K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,986 |
1,983 |
$127K |
| D1120 |
Prophylaxis - child |
3,348 |
3,341 |
$126K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
1,154 |
473 |
$77K |
| D0210 |
Intraoral - complete series of radiographic images |
1,575 |
1,573 |
$74K |
| D2140 |
|
1,369 |
603 |
$73K |
| D1351 |
Sealant - per tooth |
1,264 |
290 |
$27K |
| D4910 |
|
351 |
351 |
$27K |
| D0272 |
Bitewings - two radiographic images |
2,179 |
2,171 |
$26K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,609 |
2,907 |
$22K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
46 |
27 |
$22K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,633 |
1,626 |
$20K |
| D1206 |
Topical application of fluoride varnish |
2,011 |
2,010 |
$19K |
| D4341 |
|
179 |
48 |
$13K |
| D0274 |
Bitewings - four radiographic images |
356 |
356 |
$6K |
| D1110 |
Prophylaxis - adult |
55 |
55 |
$5K |
| D0350 |
|
170 |
65 |
$2K |
| D1330 |
|
29 |
29 |
$0.00 |