| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
17,626 |
17,618 |
$374K |
| D1110 |
Prophylaxis - adult |
9,729 |
9,727 |
$352K |
| D1120 |
Prophylaxis - child |
8,429 |
8,424 |
$282K |
| D1351 |
Sealant - per tooth |
6,211 |
1,953 |
$268K |
| D0274 |
Bitewings - four radiographic images |
9,530 |
9,530 |
$185K |
| D2750 |
|
486 |
361 |
$164K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,801 |
1,843 |
$160K |
| D0220 |
Intraoral - periapical first radiographic image |
13,877 |
13,756 |
$135K |
| D1208 |
Topical application of fluoride, excluding varnish |
10,729 |
10,724 |
$128K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,375 |
967 |
$94K |
| D0230 |
Intraoral - periapical each additional radiographic image |
12,405 |
12,371 |
$69K |
| D0210 |
Intraoral - complete series of radiographic images |
3,953 |
3,846 |
$51K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,272 |
757 |
$45K |
| D2954 |
|
472 |
360 |
$43K |
| D0140 |
Limited oral evaluation - problem focused |
4,240 |
3,477 |
$43K |
| D4341 |
|
1,203 |
353 |
$42K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
85 |
64 |
$32K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,263 |
1,263 |
$26K |
| D0272 |
Bitewings - two radiographic images |
1,998 |
1,998 |
$25K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
402 |
257 |
$24K |
| D9310 |
|
370 |
370 |
$18K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
74 |
72 |
$18K |
| D0330 |
Panoramic radiographic image |
890 |
890 |
$17K |
| D0340 |
|
357 |
357 |
$14K |
| D7140 |
Extraction, erupted tooth or exposed root |
319 |
196 |
$11K |
| D3320 |
|
53 |
45 |
$9K |
| D2335 |
|
91 |
54 |
$8K |
| D0350 |
|
392 |
392 |
$4K |
| D2332 |
|
60 |
40 |
$4K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
35 |
28 |
$2K |
| D1320 |
|
152 |
152 |
$1K |
| D2394 |
|
14 |
13 |
$1K |
| D0601 |
|
262 |
262 |
$186.00 |