| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
4,132 |
4,089 |
$246K |
| D1110 |
Prophylaxis - adult |
2,359 |
2,344 |
$208K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
2,438 |
1,315 |
$162K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,086 |
2,073 |
$128K |
| D1120 |
Prophylaxis - child |
3,156 |
3,112 |
$123K |
| D0230 |
Intraoral - periapical each additional radiographic image |
22,458 |
5,053 |
$104K |
| D0210 |
Intraoral - complete series of radiographic images |
1,714 |
1,704 |
$81K |
| D9430 |
|
2,456 |
2,194 |
$78K |
| D1208 |
Topical application of fluoride, excluding varnish |
5,595 |
5,538 |
$70K |
| D2160 |
|
875 |
576 |
$69K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
138 |
103 |
$66K |
| D4341 |
|
844 |
244 |
$59K |
| D0272 |
Bitewings - two radiographic images |
3,492 |
3,459 |
$41K |
| D4910 |
|
389 |
379 |
$30K |
| D1351 |
Sealant - per tooth |
927 |
228 |
$28K |
| D0350 |
|
3,028 |
1,469 |
$28K |
| D0220 |
Intraoral - periapical first radiographic image |
1,452 |
1,430 |
$17K |
| D2140 |
|
297 |
204 |
$16K |
| D2954 |
|
45 |
37 |
$5K |
| D9993 |
|
28 |
28 |
$2K |
| D1310 |
|
28 |
28 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
20 |
12 |
$1K |
| D0602 |
|
40 |
40 |
$566.25 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$360.00 |