| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,143 |
3,138 |
$143K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,574 |
1,006 |
$110K |
| D0120 |
Periodic oral evaluation - established patient |
4,222 |
4,216 |
$108K |
| D1206 |
Topical application of fluoride varnish |
3,051 |
3,047 |
$96K |
| D1120 |
Prophylaxis - child |
1,631 |
1,631 |
$75K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
726 |
482 |
$40K |
| D0274 |
Bitewings - four radiographic images |
2,660 |
2,655 |
$32K |
| D2740 |
Crown - porcelain/ceramic |
41 |
31 |
$20K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
34 |
31 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
694 |
693 |
$18K |
| D0140 |
Limited oral evaluation - problem focused |
315 |
309 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,289 |
2,280 |
$13K |
| D1351 |
Sealant - per tooth |
669 |
137 |
$13K |
| D0210 |
Intraoral - complete series of radiographic images |
293 |
293 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
2,599 |
2,586 |
$13K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
75 |
65 |
$7K |
| D0272 |
Bitewings - two radiographic images |
499 |
499 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
192 |
192 |
$5K |
| D0603 |
|
476 |
476 |
$5K |
| D2954 |
|
40 |
37 |
$4K |
| D1353 |
|
140 |
24 |
$1K |
| D2331 |
|
20 |
16 |
$1K |
| D2332 |
|
15 |
12 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
33 |
31 |
$815.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
13 |
12 |
$677.50 |