| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,213 |
3,199 |
$26K |
| D0210 |
Intraoral - complete series of radiographic images |
1,320 |
1,315 |
$25K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,617 |
1,611 |
$21K |
| D0140 |
Limited oral evaluation - problem focused |
2,045 |
1,986 |
$18K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,080 |
808 |
$17K |
| D1206 |
Topical application of fluoride varnish |
4,669 |
4,647 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
733 |
538 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
2,620 |
2,547 |
$7K |
| D1120 |
Prophylaxis - child |
788 |
784 |
$7K |
| D0274 |
Bitewings - four radiographic images |
1,570 |
1,560 |
$6K |
| D4910 |
|
787 |
782 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
1,592 |
1,585 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
130 |
115 |
$4K |
| D4342 |
|
285 |
152 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,266 |
991 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
86 |
47 |
$3K |
| D0270 |
|
1,205 |
1,182 |
$3K |
| D4341 |
|
85 |
38 |
$1K |
| D0330 |
Panoramic radiographic image |
417 |
413 |
$1K |
| D9310 |
|
132 |
132 |
$720.00 |
| D1351 |
Sealant - per tooth |
120 |
37 |
$455.00 |
| D0191 |
|
39 |
39 |
$216.00 |
| D0272 |
Bitewings - two radiographic images |
32 |
32 |
$100.00 |
| D4346 |
|
12 |
12 |
$88.00 |
| D0603 |
|
13 |
13 |
$55.00 |
| D1330 |
|
6,360 |
5,969 |
$20.00 |
| D1320 |
|
156 |
152 |
$0.00 |
| D1310 |
|
4,924 |
4,638 |
$0.00 |
| D9995 |
|
78 |
78 |
$0.00 |
| D4921 |
|
703 |
309 |
$0.00 |