| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
4,698 |
4,680 |
$178K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,646 |
1,277 |
$165K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,875 |
1,192 |
$159K |
| D0120 |
Periodic oral evaluation - established patient |
5,651 |
5,629 |
$120K |
| D0210 |
Intraoral - complete series of radiographic images |
2,403 |
2,350 |
$93K |
| D2740 |
Crown - porcelain/ceramic |
145 |
97 |
$87K |
| D0274 |
Bitewings - four radiographic images |
2,477 |
2,472 |
$60K |
| D2950 |
|
371 |
280 |
$56K |
| D1120 |
Prophylaxis - child |
1,121 |
1,117 |
$45K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,636 |
1,631 |
$44K |
| D0140 |
Limited oral evaluation - problem focused |
1,586 |
1,556 |
$38K |
| D0220 |
Intraoral - periapical first radiographic image |
3,572 |
3,111 |
$32K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,185 |
1,185 |
$28K |
| D2335 |
|
341 |
106 |
$25K |
| D0330 |
Panoramic radiographic image |
912 |
907 |
$25K |
| D4355 |
|
572 |
568 |
$22K |
| D2750 |
|
47 |
31 |
$19K |
| D2790 |
|
29 |
28 |
$14K |
| D3320 |
|
33 |
27 |
$14K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
209 |
145 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,788 |
1,442 |
$9K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
12 |
12 |
$6K |
| D1351 |
Sealant - per tooth |
113 |
25 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
61 |
38 |
$2K |
| D2330 |
|
57 |
40 |
$2K |
| D1206 |
Topical application of fluoride varnish |
49 |
49 |
$1K |