| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
9,548 |
9,545 |
$344K |
| D0274 |
Bitewings - four radiographic images |
11,112 |
11,112 |
$217K |
| D0120 |
Periodic oral evaluation - established patient |
8,850 |
8,850 |
$181K |
| D1351 |
Sealant - per tooth |
2,706 |
902 |
$130K |
| D0220 |
Intraoral - periapical first radiographic image |
13,345 |
13,318 |
$128K |
| D1120 |
Prophylaxis - child |
3,411 |
3,411 |
$105K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,971 |
3,970 |
$83K |
| D0230 |
Intraoral - periapical each additional radiographic image |
11,807 |
11,798 |
$61K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
951 |
710 |
$56K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
830 |
509 |
$49K |
| D2954 |
|
423 |
331 |
$40K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
809 |
606 |
$35K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,746 |
2,744 |
$31K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
507 |
443 |
$30K |
| D1206 |
Topical application of fluoride varnish |
1,201 |
1,201 |
$29K |
| D7140 |
Extraction, erupted tooth or exposed root |
680 |
284 |
$23K |
| D0210 |
Intraoral - complete series of radiographic images |
3,272 |
3,249 |
$19K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
38 |
31 |
$14K |
| D2750 |
|
22 |
18 |
$8K |
| D3320 |
|
35 |
29 |
$7K |
| D0330 |
Panoramic radiographic image |
395 |
395 |
$4K |
| D0272 |
Bitewings - two radiographic images |
182 |
182 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
76 |
76 |
$701.76 |
| D9310 |
|
12 |
12 |
$596.76 |