| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,594 |
2,588 |
$168K |
| D0120 |
Periodic oral evaluation - established patient |
1,471 |
1,470 |
$97K |
| D1120 |
Prophylaxis - child |
2,379 |
2,372 |
$91K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
1,142 |
719 |
$76K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,657 |
3,343 |
$75K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
460 |
204 |
$54K |
| D0210 |
Intraoral - complete series of radiographic images |
1,024 |
1,022 |
$48K |
| D4341 |
|
636 |
169 |
$45K |
| D2140 |
|
694 |
392 |
$37K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,448 |
2,441 |
$28K |
| D0350 |
|
1,371 |
1,152 |
$26K |
| D1351 |
Sealant - per tooth |
682 |
211 |
$20K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
34 |
27 |
$16K |
| D0274 |
Bitewings - four radiographic images |
534 |
534 |
$11K |
| D0272 |
Bitewings - two radiographic images |
749 |
748 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
99 |
59 |
$7K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
13 |
12 |
$6K |
| D4910 |
|
72 |
72 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
70 |
26 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
297 |
285 |
$4K |
| D2330 |
|
38 |
25 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
41 |
19 |
$2K |
| D9430 |
|
28 |
26 |
$896.00 |
| D1330 |
|
15 |
13 |
$0.00 |