| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,140 |
2,132 |
$131K |
| D0120 |
Periodic oral evaluation - established patient |
1,456 |
1,451 |
$87K |
| D1120 |
Prophylaxis - child |
1,692 |
1,680 |
$63K |
| D0210 |
Intraoral - complete series of radiographic images |
1,281 |
1,275 |
$60K |
| D0230 |
Intraoral - periapical each additional radiographic image |
13,953 |
2,761 |
$58K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
70 |
53 |
$33K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
489 |
259 |
$33K |
| D0274 |
Bitewings - four radiographic images |
1,399 |
1,395 |
$29K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,368 |
2,355 |
$28K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
315 |
154 |
$21K |
| D8670 |
Periodic orthodontic treatment visit |
30 |
30 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
130 |
67 |
$7K |
| D1110 |
Prophylaxis - adult |
76 |
76 |
$7K |
| D2954 |
|
34 |
25 |
$4K |
| D2140 |
|
55 |
42 |
$3K |
| D2160 |
|
34 |
24 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
30 |
21 |
$2K |
| D2161 |
|
18 |
12 |
$2K |
| D1351 |
Sealant - per tooth |
49 |
12 |
$1K |
| D0350 |
|
88 |
50 |
$771.60 |
| D0272 |
Bitewings - two radiographic images |
68 |
68 |
$753.00 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$440.00 |
| D9430 |
|
12 |
12 |
$384.00 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$144.00 |