| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
3,160 |
3,135 |
$194K |
| D1110 |
Prophylaxis - adult |
1,871 |
1,847 |
$165K |
| D1120 |
Prophylaxis - child |
2,200 |
2,192 |
$91K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,006 |
3,974 |
$55K |
| D0210 |
Intraoral - complete series of radiographic images |
1,109 |
1,101 |
$52K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
106 |
85 |
$50K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
703 |
700 |
$46K |
| D0230 |
Intraoral - periapical each additional radiographic image |
10,439 |
3,794 |
$44K |
| D0274 |
Bitewings - four radiographic images |
2,082 |
2,061 |
$43K |
| D9430 |
|
1,310 |
1,288 |
$41K |
| D0350 |
|
3,542 |
1,206 |
$31K |
| D2140 |
|
365 |
148 |
$19K |
| D1351 |
Sealant - per tooth |
588 |
128 |
$16K |
| D4910 |
|
91 |
91 |
$7K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
92 |
45 |
$6K |
| D2161 |
|
59 |
38 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
83 |
39 |
$5K |
| D2394 |
|
26 |
14 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
30 |
14 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
30 |
12 |
$2K |
| D2160 |
|
20 |
12 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
54 |
54 |
$648.00 |
| D1206 |
Topical application of fluoride varnish |
27 |
27 |
$238.00 |
| D1999 |
|
16 |
16 |
$0.00 |
| D0999 |
Unspecified diagnostic procedure, by report |
105 |
105 |
$0.00 |