| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,405 |
2,392 |
$122K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,810 |
1,802 |
$111K |
| D1120 |
Prophylaxis - child |
2,418 |
2,399 |
$85K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,628 |
3,921 |
$78K |
| D1110 |
Prophylaxis - adult |
923 |
919 |
$75K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
805 |
378 |
$53K |
| D0274 |
Bitewings - four radiographic images |
2,266 |
2,251 |
$46K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
79 |
62 |
$38K |
| D4341 |
|
504 |
160 |
$33K |
| D1351 |
Sealant - per tooth |
1,495 |
332 |
$24K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,440 |
1,434 |
$19K |
| D1206 |
Topical application of fluoride varnish |
1,392 |
1,383 |
$15K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
126 |
28 |
$12K |
| D2954 |
|
103 |
79 |
$11K |
| D0210 |
Intraoral - complete series of radiographic images |
161 |
161 |
$7K |
| D0272 |
Bitewings - two radiographic images |
594 |
592 |
$7K |
| D2160 |
|
71 |
43 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
78 |
49 |
$5K |
| D1310 |
|
658 |
657 |
$5K |
| D9430 |
|
142 |
134 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
62 |
33 |
$4K |
| D2140 |
|
59 |
40 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
185 |
180 |
$2K |
| D1320 |
|
110 |
110 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
32 |
25 |
$2K |
| D9993 |
|
520 |
520 |
$1K |
| D9248 |
|
28 |
28 |
$980.00 |
| D4910 |
|
12 |
12 |
$924.00 |
| D0601 |
|
410 |
410 |
$825.00 |
| D9110 |
|
13 |
13 |
$819.00 |
| D1999 |
|
13 |
13 |
$46.00 |
| D1330 |
|
1,762 |
1,752 |
$0.00 |