| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
3,927 |
3,916 |
$199K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,534 |
2,526 |
$157K |
| D1120 |
Prophylaxis - child |
3,967 |
3,956 |
$138K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
2,037 |
1,277 |
$135K |
| D0230 |
Intraoral - periapical each additional radiographic image |
28,882 |
5,322 |
$116K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
217 |
163 |
$103K |
| D0274 |
Bitewings - four radiographic images |
3,628 |
3,619 |
$75K |
| D2140 |
|
1,132 |
722 |
$61K |
| D0210 |
Intraoral - complete series of radiographic images |
1,250 |
1,247 |
$58K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,904 |
4,891 |
$55K |
| D1351 |
Sealant - per tooth |
1,501 |
522 |
$37K |
| D4341 |
|
379 |
156 |
$26K |
| D2160 |
|
312 |
236 |
$25K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
171 |
103 |
$20K |
| D2954 |
|
172 |
136 |
$18K |
| D9430 |
|
560 |
552 |
$17K |
| D1110 |
Prophylaxis - adult |
186 |
183 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
732 |
727 |
$8K |
| D0272 |
Bitewings - two radiographic images |
662 |
659 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
108 |
79 |
$6K |
| D0350 |
|
131 |
121 |
$778.50 |
| D0270 |
|
14 |
14 |
$60.00 |