| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
5,491 |
5,491 |
$302K |
| D1110 |
Prophylaxis - adult |
2,948 |
2,946 |
$251K |
| D1120 |
Prophylaxis - child |
3,154 |
3,154 |
$119K |
| D0210 |
Intraoral - complete series of radiographic images |
2,068 |
2,067 |
$96K |
| D1351 |
Sealant - per tooth |
3,059 |
757 |
$83K |
| D1208 |
Topical application of fluoride, excluding varnish |
6,089 |
6,086 |
$77K |
| D0274 |
Bitewings - four radiographic images |
3,247 |
3,247 |
$68K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
100 |
79 |
$46K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
790 |
417 |
$42K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
631 |
631 |
$42K |
| D0230 |
Intraoral - periapical each additional radiographic image |
10,380 |
5,370 |
$41K |
| D0350 |
|
4,139 |
2,061 |
$40K |
| D9430 |
|
1,155 |
1,109 |
$36K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
319 |
244 |
$21K |
| D0220 |
Intraoral - periapical first radiographic image |
1,756 |
1,724 |
$20K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
138 |
88 |
$16K |
| D2954 |
|
131 |
110 |
$14K |
| D2330 |
|
116 |
68 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
146 |
66 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
110 |
77 |
$7K |
| D4341 |
|
52 |
13 |
$4K |
| D0272 |
Bitewings - two radiographic images |
245 |
245 |
$3K |
| D2140 |
|
19 |
15 |
$1K |
| D1999 |
|
122 |
115 |
$40.00 |