| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,245 |
2,228 |
$163K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,200 |
2,190 |
$146K |
| D1110 |
Prophylaxis - adult |
1,555 |
1,533 |
$138K |
| D1120 |
Prophylaxis - child |
2,689 |
2,671 |
$119K |
| D0210 |
Intraoral - complete series of radiographic images |
1,682 |
1,672 |
$80K |
| D0230 |
Intraoral - periapical each additional radiographic image |
20,139 |
3,195 |
$78K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
676 |
397 |
$37K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,593 |
2,581 |
$35K |
| D0274 |
Bitewings - four radiographic images |
1,478 |
1,469 |
$27K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
359 |
257 |
$24K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
41 |
26 |
$20K |
| D9430 |
|
582 |
572 |
$19K |
| D0220 |
Intraoral - periapical first radiographic image |
1,538 |
1,515 |
$18K |
| D4341 |
|
229 |
66 |
$16K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
135 |
97 |
$9K |
| D1351 |
Sealant - per tooth |
402 |
87 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
66 |
37 |
$4K |
| D4910 |
|
41 |
41 |
$3K |
| D2160 |
|
12 |
12 |
$957.60 |
| D0272 |
Bitewings - two radiographic images |
70 |
70 |
$816.00 |
| D0270 |
|
12 |
12 |
$60.00 |