| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
4,036 |
4,012 |
$217K |
| D1120 |
Prophylaxis - child |
3,512 |
3,500 |
$133K |
| D0230 |
Intraoral - periapical each additional radiographic image |
26,314 |
5,127 |
$116K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
1,375 |
774 |
$91K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,608 |
1,605 |
$90K |
| D1110 |
Prophylaxis - adult |
845 |
842 |
$73K |
| D0274 |
Bitewings - four radiographic images |
2,894 |
2,883 |
$61K |
| D1208 |
Topical application of fluoride, excluding varnish |
5,009 |
4,996 |
$59K |
| D0210 |
Intraoral - complete series of radiographic images |
581 |
580 |
$27K |
| D0350 |
|
2,007 |
1,007 |
$19K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
36 |
24 |
$17K |
| D0272 |
Bitewings - two radiographic images |
843 |
843 |
$10K |
| D2140 |
|
149 |
92 |
$8K |
| D1351 |
Sealant - per tooth |
180 |
54 |
$5K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
38 |
25 |
$4K |
| D4910 |
|
39 |
39 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
209 |
208 |
$2K |
| D1999 |
|
499 |
478 |
$276.00 |