| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
5,050 |
5,049 |
$274K |
| D0120 |
Periodic oral evaluation - established patient |
8,252 |
8,250 |
$226K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,025 |
1,795 |
$209K |
| D1120 |
Prophylaxis - child |
4,457 |
4,456 |
$184K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,910 |
1,619 |
$137K |
| D0330 |
Panoramic radiographic image |
2,866 |
2,865 |
$110K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,569 |
1,262 |
$103K |
| D1351 |
Sealant - per tooth |
1,170 |
769 |
$99K |
| D0274 |
Bitewings - four radiographic images |
2,166 |
2,166 |
$61K |
| D2740 |
Crown - porcelain/ceramic |
94 |
86 |
$52K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,739 |
3,738 |
$52K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,487 |
1,487 |
$43K |
| D0220 |
Intraoral - periapical first radiographic image |
2,791 |
2,523 |
$34K |
| D1206 |
Topical application of fluoride varnish |
1,019 |
1,019 |
$30K |
| D0272 |
Bitewings - two radiographic images |
1,541 |
1,540 |
$27K |
| D0140 |
Limited oral evaluation - problem focused |
2,001 |
1,939 |
$26K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
219 |
191 |
$24K |
| D2335 |
|
97 |
83 |
$17K |
| D0210 |
Intraoral - complete series of radiographic images |
407 |
400 |
$7K |
| D2330 |
|
102 |
87 |
$7K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
28 |
26 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
281 |
272 |
$2K |
| D0270 |
|
12 |
12 |
$158.06 |
| D1353 |
|
165 |
111 |
$0.00 |
| D9994 |
|
32 |
32 |
$0.00 |