| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,831 |
2,816 |
$246K |
| D0120 |
Periodic oral evaluation - established patient |
4,345 |
4,329 |
$238K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,922 |
2,912 |
$186K |
| D0230 |
Intraoral - periapical each additional radiographic image |
42,515 |
7,875 |
$180K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
1,502 |
998 |
$178K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
340 |
282 |
$162K |
| D0274 |
Bitewings - four radiographic images |
6,084 |
6,064 |
$130K |
| D1120 |
Prophylaxis - child |
3,310 |
3,301 |
$126K |
| D1206 |
Topical application of fluoride varnish |
5,477 |
5,456 |
$80K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
936 |
654 |
$62K |
| D1351 |
Sealant - per tooth |
1,791 |
396 |
$49K |
| D9430 |
|
1,143 |
1,114 |
$36K |
| D0220 |
Intraoral - periapical first radiographic image |
2,031 |
1,939 |
$24K |
| D2160 |
|
201 |
159 |
$16K |
| D7140 |
Extraction, erupted tooth or exposed root |
178 |
115 |
$10K |
| D2140 |
|
183 |
126 |
$10K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
16 |
16 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
784 |
779 |
$7K |
| D0272 |
Bitewings - two radiographic images |
621 |
620 |
$7K |
| D2330 |
|
58 |
38 |
$5K |
| D4341 |
|
47 |
14 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
18 |
12 |
$982.80 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
14 |
12 |
$940.80 |
| D9993 |
|
12 |
12 |
$760.00 |
| D1310 |
|
12 |
12 |
$552.00 |