| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,759 |
2,755 |
$145K |
| D1120 |
Prophylaxis - child |
2,498 |
2,490 |
$91K |
| D0274 |
Bitewings - four radiographic images |
2,447 |
2,444 |
$51K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
737 |
737 |
$44K |
| D0230 |
Intraoral - periapical each additional radiographic image |
9,799 |
3,981 |
$43K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
86 |
54 |
$41K |
| D4910 |
|
397 |
394 |
$31K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,456 |
2,449 |
$27K |
| D9430 |
|
572 |
566 |
$18K |
| D2160 |
|
162 |
90 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
975 |
956 |
$11K |
| D1110 |
Prophylaxis - adult |
111 |
110 |
$9K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
121 |
72 |
$8K |
| D1351 |
Sealant - per tooth |
224 |
53 |
$6K |
| D4341 |
|
93 |
24 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
115 |
115 |
$5K |
| D0272 |
Bitewings - two radiographic images |
239 |
238 |
$3K |
| D2954 |
|
25 |
15 |
$3K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
19 |
14 |
$2K |
| D2161 |
|
22 |
12 |
$2K |