| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,769 |
1,760 |
$143K |
| D0120 |
Periodic oral evaluation - established patient |
2,976 |
2,946 |
$137K |
| D2740 |
Crown - porcelain/ceramic |
270 |
223 |
$127K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,858 |
1,851 |
$113K |
| D0210 |
Intraoral - complete series of radiographic images |
1,956 |
1,949 |
$91K |
| D1120 |
Prophylaxis - child |
1,841 |
1,832 |
$67K |
| D9430 |
|
1,566 |
1,515 |
$49K |
| D4910 |
|
521 |
520 |
$39K |
| D4341 |
|
557 |
165 |
$38K |
| D0230 |
Intraoral - periapical each additional radiographic image |
9,228 |
3,141 |
$37K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,425 |
2,416 |
$29K |
| D0220 |
Intraoral - periapical first radiographic image |
1,689 |
1,626 |
$20K |
| D1351 |
Sealant - per tooth |
648 |
171 |
$16K |
| D0330 |
Panoramic radiographic image |
530 |
530 |
$15K |
| D0274 |
Bitewings - four radiographic images |
656 |
655 |
$14K |
| D0272 |
Bitewings - two radiographic images |
1,113 |
1,109 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
106 |
76 |
$6K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
86 |
57 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
32 |
25 |
$2K |
| D2954 |
|
13 |
12 |
$1K |
| D4342 |
|
28 |
12 |
$1K |
| D1206 |
Topical application of fluoride varnish |
61 |
61 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
16 |
12 |
$746.20 |
| D1999 |
|
89 |
89 |
$0.00 |