| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,575 |
2,556 |
$153K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,128 |
2,116 |
$130K |
| D1110 |
Prophylaxis - adult |
1,439 |
1,434 |
$122K |
| D1120 |
Prophylaxis - child |
2,239 |
2,224 |
$85K |
| D0210 |
Intraoral - complete series of radiographic images |
1,768 |
1,759 |
$82K |
| D0230 |
Intraoral - periapical each additional radiographic image |
13,845 |
3,156 |
$56K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
691 |
329 |
$46K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,736 |
3,710 |
$45K |
| D0274 |
Bitewings - four radiographic images |
2,162 |
2,146 |
$45K |
| D0350 |
|
2,625 |
1,047 |
$25K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
39 |
30 |
$19K |
| D1351 |
Sealant - per tooth |
810 |
225 |
$18K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
323 |
164 |
$17K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
101 |
48 |
$12K |
| D9430 |
|
230 |
223 |
$7K |
| D2140 |
|
84 |
42 |
$5K |
| D2160 |
|
37 |
26 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
26 |
15 |
$2K |
| D0272 |
Bitewings - two radiographic images |
37 |
37 |
$420.00 |