| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
3,813 |
3,807 |
$202K |
| D1110 |
Prophylaxis - adult |
1,571 |
1,564 |
$131K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
269 |
191 |
$128K |
| D1120 |
Prophylaxis - child |
2,859 |
2,858 |
$103K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
1,300 |
824 |
$87K |
| D0230 |
Intraoral - periapical each additional radiographic image |
20,072 |
3,891 |
$80K |
| D0210 |
Intraoral - complete series of radiographic images |
1,464 |
1,458 |
$68K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
940 |
938 |
$58K |
| D0274 |
Bitewings - four radiographic images |
2,556 |
2,554 |
$54K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,393 |
4,376 |
$52K |
| D2140 |
|
776 |
427 |
$42K |
| D0350 |
|
3,620 |
1,310 |
$35K |
| D1351 |
Sealant - per tooth |
566 |
144 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
247 |
121 |
$13K |
| D2160 |
|
154 |
120 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
629 |
621 |
$7K |
| D9430 |
|
207 |
198 |
$6K |
| D4341 |
|
61 |
17 |
$4K |
| D4910 |
|
44 |
44 |
$3K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
15 |
12 |
$2K |
| D2952 |
|
15 |
14 |
$2K |
| D0272 |
Bitewings - two radiographic images |
59 |
59 |
$638.00 |
| D1999 |
|
20 |
20 |
$0.00 |