| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,273 |
2,264 |
$178K |
| D1120 |
Prophylaxis - child |
2,810 |
2,798 |
$135K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,945 |
1,939 |
$129K |
| D1351 |
Sealant - per tooth |
3,114 |
1,154 |
$106K |
| D1110 |
Prophylaxis - adult |
1,141 |
1,139 |
$101K |
| D0230 |
Intraoral - periapical each additional radiographic image |
23,707 |
4,340 |
$98K |
| D0274 |
Bitewings - four radiographic images |
3,544 |
3,533 |
$76K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,976 |
3,963 |
$57K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
560 |
316 |
$37K |
| D0350 |
|
3,861 |
1,224 |
$37K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
513 |
242 |
$28K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
50 |
42 |
$24K |
| D9430 |
|
659 |
632 |
$21K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
249 |
122 |
$17K |
| D7140 |
Extraction, erupted tooth or exposed root |
289 |
151 |
$16K |
| D2160 |
|
122 |
77 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
693 |
682 |
$8K |
| D2954 |
|
28 |
24 |
$3K |
| D4341 |
|
37 |
12 |
$3K |
| D1310 |
|
53 |
52 |
$2K |
| D0272 |
Bitewings - two radiographic images |
185 |
185 |
$2K |
| D0601 |
|
38 |
38 |
$555.00 |