| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,854 |
2,830 |
$149K |
| D0230 |
Intraoral - periapical each additional radiographic image |
23,239 |
4,586 |
$96K |
| D1120 |
Prophylaxis - child |
2,499 |
2,480 |
$91K |
| D0274 |
Bitewings - four radiographic images |
2,892 |
2,864 |
$60K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,549 |
3,521 |
$43K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
703 |
703 |
$42K |
| D1110 |
Prophylaxis - adult |
307 |
307 |
$27K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
214 |
111 |
$25K |
| D1351 |
Sealant - per tooth |
776 |
187 |
$20K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
283 |
159 |
$19K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
17 |
12 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
90 |
44 |
$5K |
| D2140 |
|
86 |
54 |
$5K |
| D9430 |
|
86 |
86 |
$3K |
| D4341 |
|
51 |
14 |
$3K |
| D4910 |
|
25 |
25 |
$2K |
| D0272 |
Bitewings - two radiographic images |
164 |
164 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
29 |
26 |
$2K |
| D0350 |
|
177 |
80 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
71 |
71 |
$764.00 |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$576.00 |
| D0330 |
Panoramic radiographic image |
17 |
17 |
$400.00 |
| D1330 |
|
14 |
14 |
$0.00 |
| D1310 |
|
13 |
13 |
$0.00 |