| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,800 |
2,793 |
$154K |
| D1120 |
Prophylaxis - child |
2,848 |
2,842 |
$109K |
| D1110 |
Prophylaxis - adult |
1,236 |
1,226 |
$105K |
| D0230 |
Intraoral - periapical each additional radiographic image |
25,448 |
4,558 |
$105K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,484 |
1,479 |
$94K |
| D0274 |
Bitewings - four radiographic images |
2,906 |
2,894 |
$62K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
101 |
83 |
$48K |
| D9430 |
|
1,304 |
1,291 |
$41K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,975 |
2,969 |
$35K |
| D1351 |
Sealant - per tooth |
1,180 |
274 |
$32K |
| D0350 |
|
3,277 |
941 |
$28K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
288 |
180 |
$19K |
| D0330 |
Panoramic radiographic image |
630 |
625 |
$19K |
| D1206 |
Topical application of fluoride varnish |
1,087 |
1,079 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
1,257 |
1,251 |
$15K |
| D0272 |
Bitewings - two radiographic images |
1,181 |
1,181 |
$14K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
93 |
41 |
$11K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
151 |
72 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
105 |
64 |
$6K |
| D2954 |
|
26 |
25 |
$3K |
| D2160 |
|
23 |
13 |
$2K |
| D9993 |
|
28 |
28 |
$2K |
| D1310 |
|
28 |
28 |
$1K |