| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
4,417 |
4,153 |
$147K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,652 |
886 |
$123K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,497 |
798 |
$93K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,971 |
3,330 |
$84K |
| D1206 |
Topical application of fluoride varnish |
3,108 |
3,066 |
$56K |
| D0120 |
Periodic oral evaluation - established patient |
3,787 |
3,675 |
$53K |
| D0330 |
Panoramic radiographic image |
1,351 |
1,119 |
$53K |
| D0274 |
Bitewings - four radiographic images |
2,589 |
2,413 |
$53K |
| D9630 |
|
3,526 |
3,491 |
$44K |
| D0210 |
Intraoral - complete series of radiographic images |
1,284 |
944 |
$38K |
| D1120 |
Prophylaxis - child |
1,148 |
1,134 |
$35K |
| D0140 |
Limited oral evaluation - problem focused |
1,236 |
1,061 |
$23K |
| D0220 |
Intraoral - periapical first radiographic image |
2,618 |
2,171 |
$20K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
150 |
67 |
$17K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,045 |
432 |
$10K |
| D9920 |
|
120 |
117 |
$8K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
68 |
39 |
$8K |
| D1351 |
Sealant - per tooth |
172 |
54 |
$4K |
| D2950 |
|
31 |
24 |
$3K |
| D9994 |
|
1,471 |
1,466 |
$0.00 |
| D8670 |
Periodic orthodontic treatment visit |
12 |
12 |
$0.00 |
| D2740 |
Crown - porcelain/ceramic |
31 |
15 |
$0.00 |
| D8660 |
|
13 |
13 |
$0.00 |
| D4341 |
|
51 |
14 |
$0.00 |