| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,562 |
2,558 |
$228K |
| D0120 |
Periodic oral evaluation - established patient |
2,127 |
2,122 |
$159K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,074 |
2,072 |
$137K |
| D4341 |
|
1,553 |
417 |
$109K |
| D4910 |
|
1,322 |
1,319 |
$101K |
| D0230 |
Intraoral - periapical each additional radiographic image |
21,947 |
4,385 |
$91K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,311 |
606 |
$71K |
| D2740 |
Crown - porcelain/ceramic |
136 |
87 |
$65K |
| D1206 |
Topical application of fluoride varnish |
3,669 |
3,661 |
$61K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
898 |
490 |
$60K |
| D1120 |
Prophylaxis - child |
1,115 |
1,112 |
$53K |
| D9430 |
|
1,583 |
1,456 |
$51K |
| D0330 |
Panoramic radiographic image |
1,688 |
1,686 |
$51K |
| D0350 |
|
4,354 |
1,755 |
$44K |
| D0272 |
Bitewings - two radiographic images |
3,048 |
3,045 |
$37K |
| D0220 |
Intraoral - periapical first radiographic image |
2,294 |
2,154 |
$27K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
284 |
150 |
$19K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
137 |
83 |
$16K |
| D7140 |
Extraction, erupted tooth or exposed root |
259 |
137 |
$15K |
| D2330 |
|
131 |
71 |
$10K |
| D2954 |
|
92 |
56 |
$10K |
| D4342 |
|
186 |
55 |
$8K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
48 |
40 |
$4K |
| D2160 |
|
40 |
25 |
$3K |
| D2140 |
|
43 |
15 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
28 |
28 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
24 |
24 |
$295.00 |