| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
5,030 |
5,021 |
$248K |
| D2750 |
|
230 |
197 |
$135K |
| D0120 |
Periodic oral evaluation - established patient |
4,927 |
4,914 |
$128K |
| D0274 |
Bitewings - four radiographic images |
4,085 |
4,081 |
$106K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
918 |
629 |
$77K |
| D0210 |
Intraoral - complete series of radiographic images |
1,241 |
1,232 |
$46K |
| D2160 |
|
400 |
301 |
$40K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,138 |
1,138 |
$34K |
| D1120 |
Prophylaxis - child |
558 |
558 |
$23K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,482 |
1,482 |
$21K |
| D0220 |
Intraoral - periapical first radiographic image |
1,495 |
1,472 |
$17K |
| D9110 |
|
493 |
490 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,035 |
1,030 |
$9K |
| D0330 |
Panoramic radiographic image |
279 |
279 |
$9K |
| D2335 |
|
26 |
14 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
35 |
24 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
53 |
40 |
$3K |
| D1351 |
Sealant - per tooth |
53 |
16 |
$2K |
| D2954 |
|
15 |
14 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
22 |
14 |
$2K |
| D0272 |
Bitewings - two radiographic images |
106 |
106 |
$2K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
17 |
12 |
$1K |
| D2140 |
|
14 |
12 |
$917.00 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
14 |
$196.00 |