| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,626 |
3,587 |
$238K |
| D1110 |
Prophylaxis - adult |
2,598 |
2,557 |
$231K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
452 |
370 |
$214K |
| D0120 |
Periodic oral evaluation - established patient |
2,284 |
2,254 |
$161K |
| D0210 |
Intraoral - complete series of radiographic images |
3,187 |
3,149 |
$150K |
| D1120 |
Prophylaxis - child |
2,410 |
2,381 |
$105K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
1,487 |
767 |
$100K |
| D2160 |
|
1,025 |
577 |
$81K |
| D4341 |
|
1,103 |
293 |
$77K |
| D1208 |
Topical application of fluoride, excluding varnish |
5,126 |
5,055 |
$72K |
| D2954 |
|
662 |
549 |
$69K |
| D1351 |
Sealant - per tooth |
2,221 |
513 |
$69K |
| D4910 |
|
629 |
622 |
$48K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
87 |
83 |
$40K |
| D0274 |
Bitewings - four radiographic images |
1,870 |
1,843 |
$39K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,051 |
2,673 |
$24K |
| D2931 |
|
154 |
137 |
$19K |
| D9430 |
|
528 |
500 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
500 |
489 |
$6K |
| D3320 |
|
13 |
12 |
$4K |
| D4342 |
|
84 |
24 |
$4K |
| D0272 |
Bitewings - two radiographic images |
272 |
272 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
48 |
28 |
$3K |
| D2161 |
|
20 |
16 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
20 |
12 |
$1K |
| D0350 |
|
110 |
39 |
$969.60 |
| D1310 |
|
12 |
12 |
$552.00 |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$211.50 |
| D0601 |
|
12 |
12 |
$180.00 |
| D9993 |
|
12 |
12 |
$0.00 |