| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
4,260 |
4,249 |
$326K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,739 |
3,720 |
$219K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,176 |
1,873 |
$200K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,636 |
1,464 |
$133K |
| D0210 |
Intraoral - complete series of radiographic images |
3,463 |
3,442 |
$123K |
| D0120 |
Periodic oral evaluation - established patient |
2,237 |
2,232 |
$94K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
166 |
152 |
$77K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
930 |
659 |
$68K |
| D4341 |
|
1,182 |
470 |
$66K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,487 |
2,481 |
$66K |
| D1120 |
Prophylaxis - child |
1,417 |
1,412 |
$62K |
| D9999 |
Unspecified adjunctive procedure, by report |
509 |
478 |
$60K |
| D1351 |
Sealant - per tooth |
1,777 |
519 |
$52K |
| D0274 |
Bitewings - four radiographic images |
2,147 |
2,144 |
$33K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
238 |
183 |
$23K |
| D4910 |
|
145 |
145 |
$14K |
| D0350 |
|
1,744 |
852 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,898 |
1,898 |
$10K |
| D2332 |
|
115 |
81 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
884 |
884 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
119 |
73 |
$6K |
| D2330 |
|
72 |
43 |
$5K |
| D1206 |
Topical application of fluoride varnish |
192 |
191 |
$3K |
| D0999 |
Unspecified diagnostic procedure, by report |
34 |
34 |
$2K |
| D0330 |
Panoramic radiographic image |
67 |
66 |
$1K |
| D4342 |
|
26 |
12 |
$972.00 |
| D1999 |
|
63 |
61 |
$260.00 |
| D0272 |
Bitewings - two radiographic images |
17 |
16 |
$152.00 |
| D1320 |
|
20 |
20 |
$150.00 |
| D0270 |
|
16 |
16 |
$70.00 |