| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
10,570 |
10,565 |
$472K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
702 |
495 |
$273K |
| D0120 |
Periodic oral evaluation - established patient |
12,122 |
12,115 |
$271K |
| D0230 |
Intraoral - periapical each additional radiographic image |
10,206 |
10,139 |
$146K |
| D0220 |
Intraoral - periapical first radiographic image |
11,828 |
11,815 |
$128K |
| D0274 |
Bitewings - four radiographic images |
5,549 |
5,548 |
$120K |
| D0330 |
Panoramic radiographic image |
3,491 |
3,489 |
$119K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,847 |
878 |
$91K |
| D1120 |
Prophylaxis - child |
2,460 |
2,460 |
$84K |
| D0210 |
Intraoral - complete series of radiographic images |
9,000 |
8,982 |
$80K |
| D1351 |
Sealant - per tooth |
1,479 |
591 |
$77K |
| D2954 |
|
597 |
461 |
$62K |
| D1208 |
Topical application of fluoride, excluding varnish |
5,049 |
5,047 |
$56K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
875 |
875 |
$21K |
| D3320 |
|
55 |
50 |
$18K |
| D2330 |
|
164 |
92 |
$8K |
| D1206 |
Topical application of fluoride varnish |
246 |
246 |
$6K |
| D4341 |
|
17 |
12 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
315 |
315 |
$4K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
16 |
13 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
26 |
25 |
$2K |