| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,004 |
1,992 |
$153K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
300 |
232 |
$143K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,847 |
1,001 |
$117K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,217 |
1,079 |
$114K |
| D0120 |
Periodic oral evaluation - established patient |
2,303 |
2,293 |
$110K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,619 |
1,612 |
$95K |
| D0230 |
Intraoral - periapical each additional radiographic image |
14,969 |
2,795 |
$58K |
| D1120 |
Prophylaxis - child |
1,625 |
1,613 |
$54K |
| D4341 |
|
646 |
231 |
$45K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
612 |
344 |
$40K |
| D0210 |
Intraoral - complete series of radiographic images |
858 |
856 |
$39K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,698 |
2,691 |
$32K |
| D0272 |
Bitewings - two radiographic images |
2,691 |
2,681 |
$28K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
144 |
87 |
$17K |
| D4910 |
|
147 |
146 |
$11K |
| D2140 |
|
214 |
114 |
$11K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
76 |
63 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
580 |
544 |
$4K |
| D0274 |
Bitewings - four radiographic images |
74 |
74 |
$1K |
| D1351 |
Sealant - per tooth |
67 |
13 |
$1K |
| D9430 |
|
13 |
12 |
$334.00 |