| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,396 |
3,388 |
$295K |
| D4910 |
|
3,306 |
3,297 |
$254K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
500 |
328 |
$238K |
| D4341 |
|
2,911 |
834 |
$197K |
| D0120 |
Periodic oral evaluation - established patient |
3,152 |
3,148 |
$197K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,162 |
2,159 |
$138K |
| D2140 |
|
2,385 |
935 |
$130K |
| D0210 |
Intraoral - complete series of radiographic images |
2,299 |
2,294 |
$109K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
1,372 |
654 |
$92K |
| D9430 |
|
2,856 |
2,631 |
$91K |
| D0330 |
Panoramic radiographic image |
2,676 |
2,667 |
$79K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,695 |
4,315 |
$73K |
| D1208 |
Topical application of fluoride, excluding varnish |
5,219 |
5,208 |
$71K |
| D0350 |
|
2,519 |
1,510 |
$63K |
| D1120 |
Prophylaxis - child |
1,592 |
1,592 |
$61K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
377 |
237 |
$45K |
| D0274 |
Bitewings - four radiographic images |
1,995 |
1,994 |
$43K |
| D4342 |
|
983 |
358 |
$41K |
| D2954 |
|
375 |
257 |
$39K |
| D0220 |
Intraoral - periapical first radiographic image |
2,012 |
1,908 |
$24K |
| D2160 |
|
170 |
103 |
$14K |
| D7140 |
Extraction, erupted tooth or exposed root |
162 |
77 |
$9K |
| D1351 |
Sealant - per tooth |
273 |
73 |
$6K |
| D1320 |
|
282 |
282 |
$5K |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$144.00 |