| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,289 |
3,272 |
$152K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,054 |
645 |
$141K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,163 |
665 |
$120K |
| D0350 |
|
1,462 |
1,391 |
$94K |
| D0120 |
Periodic oral evaluation - established patient |
3,806 |
3,781 |
$92K |
| D0330 |
Panoramic radiographic image |
1,612 |
1,592 |
$83K |
| D0274 |
Bitewings - four radiographic images |
2,279 |
2,258 |
$67K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,433 |
1,423 |
$58K |
| D0140 |
Limited oral evaluation - problem focused |
1,630 |
1,543 |
$56K |
| D1206 |
Topical application of fluoride varnish |
2,551 |
2,533 |
$51K |
| D1120 |
Prophylaxis - child |
1,461 |
1,444 |
$50K |
| D2740 |
Crown - porcelain/ceramic |
48 |
27 |
$41K |
| D1351 |
Sealant - per tooth |
849 |
237 |
$32K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
173 |
105 |
$29K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
50 |
29 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
54 |
26 |
$5K |
| D0272 |
Bitewings - two radiographic images |
218 |
218 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
312 |
304 |
$4K |
| D2332 |
|
21 |
12 |
$3K |
| D2330 |
|
27 |
12 |
$3K |
| D1353 |
|
63 |
15 |
$2K |
| D4910 |
|
25 |
24 |
$2K |
| D0460 |
|
54 |
53 |
$2K |