| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
9,685 |
9,685 |
$443K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
665 |
516 |
$304K |
| D0120 |
Periodic oral evaluation - established patient |
11,079 |
11,078 |
$253K |
| D0274 |
Bitewings - four radiographic images |
9,807 |
9,807 |
$216K |
| D0230 |
Intraoral - periapical each additional radiographic image |
10,652 |
10,638 |
$176K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,616 |
1,142 |
$107K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,298 |
1,125 |
$102K |
| D0220 |
Intraoral - periapical first radiographic image |
7,239 |
7,170 |
$78K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,445 |
1,036 |
$66K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,354 |
3,354 |
$35K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
74 |
73 |
$31K |
| D0140 |
Limited oral evaluation - problem focused |
2,552 |
2,491 |
$30K |
| D1120 |
Prophylaxis - child |
720 |
720 |
$25K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
324 |
240 |
$23K |
| D4341 |
|
420 |
207 |
$21K |
| D3320 |
|
62 |
55 |
$21K |
| D0210 |
Intraoral - complete series of radiographic images |
2,798 |
2,794 |
$17K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
212 |
174 |
$15K |
| D2954 |
|
161 |
127 |
$15K |
| D2952 |
|
102 |
89 |
$10K |
| D1351 |
Sealant - per tooth |
215 |
76 |
$9K |
| D2394 |
|
91 |
69 |
$9K |
| D2330 |
|
170 |
69 |
$7K |
| D0272 |
Bitewings - two radiographic images |
324 |
324 |
$4K |
| D1206 |
Topical application of fluoride varnish |
158 |
158 |
$4K |
| D0240 |
|
89 |
88 |
$2K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
24 |
15 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
76 |
76 |
$2K |
| D9110 |
|
59 |
58 |
$1K |
| D2332 |
|
14 |
14 |
$1K |
| D9310 |
|
14 |
14 |
$743.58 |