| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,966 |
1,961 |
$165K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,250 |
2,244 |
$143K |
| D0120 |
Periodic oral evaluation - established patient |
1,963 |
1,960 |
$113K |
| D0210 |
Intraoral - complete series of radiographic images |
2,069 |
2,065 |
$97K |
| D1120 |
Prophylaxis - child |
1,463 |
1,459 |
$54K |
| D0230 |
Intraoral - periapical each additional radiographic image |
12,135 |
2,709 |
$49K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,743 |
3,734 |
$47K |
| D9430 |
|
1,285 |
1,194 |
$40K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
586 |
312 |
$39K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
322 |
201 |
$26K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
34 |
29 |
$16K |
| D0272 |
Bitewings - two radiographic images |
1,291 |
1,288 |
$15K |
| D1320 |
|
781 |
781 |
$13K |
| D4910 |
|
128 |
128 |
$10K |
| D4341 |
|
109 |
30 |
$8K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
61 |
39 |
$7K |
| D0274 |
Bitewings - four radiographic images |
332 |
332 |
$7K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
62 |
30 |
$4K |
| D0330 |
Panoramic radiographic image |
122 |
122 |
$4K |
| D0350 |
|
352 |
133 |
$3K |
| D2954 |
|
32 |
28 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
50 |
24 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
71 |
71 |
$852.00 |
| D0270 |
|
174 |
168 |
$825.00 |
| D1351 |
Sealant - per tooth |
36 |
12 |
$792.00 |
| D1999 |
|
46 |
45 |
$0.00 |