| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,426 |
2,419 |
$203K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,693 |
2,688 |
$168K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
302 |
230 |
$144K |
| D0210 |
Intraoral - complete series of radiographic images |
2,878 |
2,867 |
$132K |
| D0120 |
Periodic oral evaluation - established patient |
1,964 |
1,953 |
$115K |
| D4341 |
|
1,099 |
291 |
$75K |
| D1351 |
Sealant - per tooth |
2,597 |
558 |
$70K |
| D0230 |
Intraoral - periapical each additional radiographic image |
12,535 |
2,403 |
$54K |
| D1206 |
Topical application of fluoride varnish |
3,691 |
3,680 |
$54K |
| D1120 |
Prophylaxis - child |
1,252 |
1,236 |
$49K |
| D4910 |
|
460 |
456 |
$35K |
| D0272 |
Bitewings - two radiographic images |
2,176 |
2,168 |
$26K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
209 |
151 |
$24K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
278 |
173 |
$18K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
158 |
99 |
$10K |
| D2954 |
|
72 |
62 |
$8K |
| D4342 |
|
79 |
24 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
16 |
12 |
$873.60 |