| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
8,427 |
8,162 |
$292K |
| D0120 |
Periodic oral evaluation - established patient |
11,064 |
10,730 |
$195K |
| D0274 |
Bitewings - four radiographic images |
7,236 |
7,002 |
$137K |
| D1351 |
Sealant - per tooth |
5,614 |
1,517 |
$127K |
| D1208 |
Topical application of fluoride, excluding varnish |
7,684 |
7,449 |
$116K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,648 |
1,057 |
$111K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,922 |
1,144 |
$104K |
| D0330 |
Panoramic radiographic image |
2,029 |
1,973 |
$95K |
| D1120 |
Prophylaxis - child |
4,477 |
4,367 |
$95K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,741 |
1,699 |
$49K |
| D2740 |
Crown - porcelain/ceramic |
52 |
32 |
$42K |
| D0140 |
Limited oral evaluation - problem focused |
1,702 |
1,587 |
$41K |
| D0272 |
Bitewings - two radiographic images |
3,207 |
3,134 |
$32K |
| D2335 |
|
351 |
199 |
$31K |
| D0220 |
Intraoral - periapical first radiographic image |
3,670 |
3,404 |
$18K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
73 |
40 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,341 |
862 |
$7K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
78 |
38 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
92 |
63 |
$5K |
| D2394 |
|
45 |
36 |
$3K |
| D2931 |
|
16 |
12 |
$2K |
| D2160 |
|
19 |
15 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
39 |
13 |
$1K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
20 |
12 |
$1K |
| D0180 |
|
24 |
24 |
$480.08 |