| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,791 |
2,782 |
$29K |
| D0210 |
Intraoral - complete series of radiographic images |
1,052 |
1,049 |
$17K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,115 |
814 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,404 |
1,400 |
$15K |
| D1206 |
Topical application of fluoride varnish |
2,870 |
2,859 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
980 |
700 |
$12K |
| D0140 |
Limited oral evaluation - problem focused |
1,082 |
1,053 |
$9K |
| D4341 |
|
493 |
208 |
$9K |
| D1120 |
Prophylaxis - child |
430 |
428 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
1,257 |
1,255 |
$5K |
| D0274 |
Bitewings - four radiographic images |
1,702 |
1,697 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
270 |
244 |
$4K |
| D4910 |
|
251 |
249 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
1,221 |
1,194 |
$3K |
| D4342 |
|
179 |
92 |
$3K |
| D0330 |
Panoramic radiographic image |
1,118 |
1,113 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
52 |
33 |
$1K |
| D0270 |
|
304 |
302 |
$770.00 |
| D2332 |
|
24 |
12 |
$594.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
597 |
415 |
$477.00 |
| D2331 |
|
39 |
28 |
$465.00 |
| D0602 |
|
58 |
58 |
$352.00 |
| D0180 |
|
45 |
45 |
$294.00 |
| D2330 |
|
36 |
27 |
$254.00 |
| D1351 |
Sealant - per tooth |
105 |
27 |
$245.00 |
| D0272 |
Bitewings - two radiographic images |
52 |
52 |
$220.00 |
| D0603 |
|
29 |
28 |
$154.00 |
| D5411 |
|
31 |
25 |
$150.00 |
| D0191 |
|
34 |
34 |
$144.00 |
| D9995 |
|
212 |
210 |
$131.00 |
| D0601 |
|
15 |
15 |
$77.00 |
| D1354 |
|
137 |
25 |
$56.00 |
| D1310 |
|
4,400 |
4,329 |
$0.00 |
| D1330 |
|
5,215 |
5,049 |
$0.00 |
| D9215 |
|
15 |
12 |
$0.00 |
| D5410 |
|
12 |
12 |
$0.00 |