| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,434 |
2,423 |
$207K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
399 |
352 |
$189K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,371 |
2,365 |
$151K |
| D0120 |
Periodic oral evaluation - established patient |
2,261 |
2,249 |
$126K |
| D0230 |
Intraoral - periapical each additional radiographic image |
24,854 |
4,578 |
$101K |
| D0274 |
Bitewings - four radiographic images |
3,573 |
3,556 |
$75K |
| D4341 |
|
1,037 |
324 |
$73K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,936 |
3,915 |
$52K |
| D1120 |
Prophylaxis - child |
1,365 |
1,357 |
$51K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
543 |
352 |
$36K |
| D2954 |
|
224 |
200 |
$23K |
| D0220 |
Intraoral - periapical first radiographic image |
1,256 |
1,215 |
$15K |
| D0350 |
|
1,209 |
722 |
$11K |
| D7140 |
Extraction, erupted tooth or exposed root |
159 |
71 |
$9K |
| D9430 |
|
170 |
167 |
$5K |
| D2140 |
|
96 |
64 |
$5K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
33 |
24 |
$4K |
| D1351 |
Sealant - per tooth |
61 |
12 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
20 |
13 |
$1K |
| D1204 |
|
16 |
16 |
$0.00 |
| D1999 |
|
21 |
21 |
$0.00 |