| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,965 |
2,942 |
$158K |
| D1120 |
Prophylaxis - child |
3,171 |
3,138 |
$119K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,821 |
1,806 |
$113K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
202 |
136 |
$94K |
| D0230 |
Intraoral - periapical each additional radiographic image |
19,629 |
4,499 |
$80K |
| D1351 |
Sealant - per tooth |
2,754 |
641 |
$76K |
| D0274 |
Bitewings - four radiographic images |
2,948 |
2,926 |
$59K |
| D9430 |
|
1,665 |
1,604 |
$52K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,484 |
3,457 |
$38K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
252 |
165 |
$29K |
| D0210 |
Intraoral - complete series of radiographic images |
655 |
653 |
$29K |
| D4910 |
|
327 |
326 |
$25K |
| D0220 |
Intraoral - periapical first radiographic image |
2,072 |
2,003 |
$24K |
| D2160 |
|
164 |
108 |
$13K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
169 |
106 |
$11K |
| D2952 |
|
61 |
41 |
$6K |
| D0350 |
|
725 |
536 |
$6K |
| D0272 |
Bitewings - two radiographic images |
452 |
449 |
$5K |
| D7111 |
|
68 |
40 |
$4K |
| D1110 |
Prophylaxis - adult |
38 |
38 |
$3K |
| D4341 |
|
39 |
12 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
18 |
12 |
$1K |
| D0270 |
|
71 |
67 |
$334.05 |