| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
5,949 |
5,923 |
$309K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
2,606 |
1,378 |
$300K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
609 |
419 |
$290K |
| D1110 |
Prophylaxis - adult |
3,100 |
3,081 |
$255K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,176 |
3,159 |
$197K |
| D0230 |
Intraoral - periapical each additional radiographic image |
46,794 |
8,614 |
$192K |
| D1120 |
Prophylaxis - child |
4,862 |
4,835 |
$180K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
2,165 |
1,435 |
$145K |
| D1351 |
Sealant - per tooth |
5,157 |
1,406 |
$132K |
| D2140 |
|
2,234 |
1,396 |
$121K |
| D0210 |
Intraoral - complete series of radiographic images |
2,458 |
2,446 |
$114K |
| D2160 |
|
1,408 |
1,101 |
$111K |
| D0274 |
Bitewings - four radiographic images |
5,112 |
5,097 |
$106K |
| D9430 |
|
3,165 |
2,941 |
$99K |
| D1206 |
Topical application of fluoride varnish |
6,528 |
6,506 |
$88K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,156 |
613 |
$66K |
| D2954 |
|
304 |
217 |
$32K |
| D0220 |
Intraoral - periapical first radiographic image |
2,305 |
2,225 |
$27K |
| D4341 |
|
308 |
80 |
$17K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,326 |
1,313 |
$11K |
| D3320 |
|
26 |
24 |
$10K |
| D0350 |
|
922 |
375 |
$9K |
| D0272 |
Bitewings - two radiographic images |
593 |
590 |
$7K |
| D4910 |
|
58 |
58 |
$4K |
| D2161 |
|
48 |
45 |
$4K |
| D0330 |
Panoramic radiographic image |
105 |
105 |
$3K |
| D9993 |
|
28 |
28 |
$2K |
| D1310 |
|
28 |
28 |
$1K |
| D9951 |
|
35 |
24 |
$994.00 |
| D1204 |
|
12 |
12 |
$0.00 |