| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
11,523 |
11,522 |
$508K |
| D0120 |
Periodic oral evaluation - established patient |
19,451 |
19,449 |
$435K |
| D0274 |
Bitewings - four radiographic images |
16,157 |
16,157 |
$364K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
4,875 |
4,137 |
$334K |
| D1120 |
Prophylaxis - child |
9,880 |
9,880 |
$328K |
| D8670 |
Periodic orthodontic treatment visit |
1,319 |
1,313 |
$284K |
| D0220 |
Intraoral - periapical first radiographic image |
19,418 |
19,360 |
$211K |
| D7140 |
Extraction, erupted tooth or exposed root |
3,545 |
2,993 |
$175K |
| D1351 |
Sealant - per tooth |
1,775 |
1,345 |
$120K |
| D1208 |
Topical application of fluoride, excluding varnish |
9,616 |
9,616 |
$114K |
| D0230 |
Intraoral - periapical each additional radiographic image |
18,293 |
18,289 |
$106K |
| D0210 |
Intraoral - complete series of radiographic images |
4,691 |
4,676 |
$100K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
1,055 |
977 |
$88K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,925 |
1,625 |
$81K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
917 |
848 |
$69K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
141 |
107 |
$59K |
| D1206 |
Topical application of fluoride varnish |
2,533 |
2,533 |
$57K |
| D4342 |
|
1,757 |
1,101 |
$47K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,984 |
1,984 |
$45K |
| D2954 |
|
371 |
311 |
$44K |
| D2140 |
|
279 |
261 |
$14K |
| D0140 |
Limited oral evaluation - problem focused |
1,232 |
1,212 |
$12K |
| D0272 |
Bitewings - two radiographic images |
715 |
715 |
$9K |
| D9945 |
|
87 |
87 |
$8K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
24 |
24 |
$7K |
| D0340 |
|
173 |
173 |
$7K |
| D0330 |
Panoramic radiographic image |
176 |
176 |
$5K |
| D8660 |
|
180 |
180 |
$5K |
| D0470 |
|
177 |
177 |
$5K |
| D4341 |
|
82 |
70 |
$4K |
| D0350 |
|
409 |
409 |
$4K |
| D2160 |
|
44 |
39 |
$3K |
| D2331 |
|
28 |
25 |
$3K |
| D3320 |
|
15 |
15 |
$3K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
14 |
14 |
$1K |
| D1330 |
|
67 |
67 |
$0.00 |