| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,269 |
2,254 |
$165K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,480 |
2,478 |
$164K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,444 |
1,215 |
$164K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,859 |
1,078 |
$155K |
| D1110 |
Prophylaxis - adult |
1,256 |
1,246 |
$112K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
232 |
168 |
$110K |
| D0210 |
Intraoral - complete series of radiographic images |
2,027 |
2,020 |
$97K |
| D1120 |
Prophylaxis - child |
2,170 |
2,166 |
$96K |
| D4341 |
|
1,269 |
382 |
$88K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,908 |
3,883 |
$54K |
| D0350 |
|
5,301 |
1,589 |
$52K |
| D4910 |
|
546 |
546 |
$42K |
| D0274 |
Bitewings - four radiographic images |
1,564 |
1,556 |
$34K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
266 |
153 |
$32K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,587 |
2,905 |
$31K |
| D9430 |
|
628 |
606 |
$20K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
120 |
92 |
$10K |
| D1351 |
Sealant - per tooth |
268 |
71 |
$6K |
| D0330 |
Panoramic radiographic image |
158 |
157 |
$5K |
| D0272 |
Bitewings - two radiographic images |
254 |
253 |
$3K |
| D9993 |
|
13 |
13 |
$845.00 |
| D1310 |
|
13 |
13 |
$598.00 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$144.00 |
| D0270 |
|
26 |
25 |
$130.00 |