| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,578 |
3,566 |
$319K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
4,101 |
4,092 |
$270K |
| D0120 |
Periodic oral evaluation - established patient |
3,108 |
3,089 |
$241K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,598 |
1,455 |
$174K |
| D0210 |
Intraoral - complete series of radiographic images |
3,256 |
3,251 |
$155K |
| D1120 |
Prophylaxis - child |
2,944 |
2,923 |
$139K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,911 |
1,035 |
$104K |
| D0230 |
Intraoral - periapical each additional radiographic image |
17,848 |
3,895 |
$72K |
| D1351 |
Sealant - per tooth |
2,103 |
450 |
$71K |
| D1206 |
Topical application of fluoride varnish |
3,544 |
3,535 |
$63K |
| D0274 |
Bitewings - four radiographic images |
2,776 |
2,755 |
$59K |
| D4910 |
|
734 |
728 |
$56K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
396 |
338 |
$47K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,931 |
2,914 |
$44K |
| D2740 |
Crown - porcelain/ceramic |
81 |
73 |
$39K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
464 |
327 |
$37K |
| D0350 |
|
3,372 |
1,413 |
$33K |
| D4341 |
|
379 |
97 |
$27K |
| D9430 |
|
727 |
710 |
$23K |
| D7140 |
Extraction, erupted tooth or exposed root |
190 |
121 |
$11K |
| D0272 |
Bitewings - two radiographic images |
682 |
680 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
443 |
435 |
$5K |
| D2330 |
|
19 |
15 |
$1K |
| D0330 |
Panoramic radiographic image |
24 |
24 |
$720.00 |