| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,323 |
2,309 |
$203K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,488 |
2,463 |
$158K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,672 |
857 |
$108K |
| D0210 |
Intraoral - complete series of radiographic images |
1,899 |
1,884 |
$88K |
| D0120 |
Periodic oral evaluation - established patient |
1,457 |
1,454 |
$86K |
| D1206 |
Topical application of fluoride varnish |
3,831 |
3,806 |
$83K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,503 |
762 |
$79K |
| D1120 |
Prophylaxis - child |
1,487 |
1,481 |
$70K |
| D2740 |
Crown - porcelain/ceramic |
108 |
76 |
$51K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,357 |
1,783 |
$37K |
| D4341 |
|
459 |
180 |
$31K |
| D4910 |
|
246 |
246 |
$23K |
| D0274 |
Bitewings - four radiographic images |
1,038 |
1,037 |
$22K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
179 |
77 |
$19K |
| D0350 |
|
2,096 |
1,105 |
$19K |
| D0220 |
Intraoral - periapical first radiographic image |
1,196 |
1,191 |
$14K |
| D1351 |
Sealant - per tooth |
327 |
84 |
$11K |
| D0272 |
Bitewings - two radiographic images |
417 |
413 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
52 |
37 |
$4K |
| D0999 |
Unspecified diagnostic procedure, by report |
28 |
21 |
$812.00 |
| D0330 |
Panoramic radiographic image |
24 |
24 |
$630.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
31 |
31 |
$380.00 |
| D9999 |
Unspecified adjunctive procedure, by report |
24 |
16 |
$200.00 |
| D0601 |
|
163 |
163 |
$165.00 |
| D0602 |
|
26 |
26 |
$20.00 |
| D0603 |
|
12 |
12 |
$10.00 |