| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
6,555 |
6,552 |
$204K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,498 |
1,771 |
$124K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
344 |
264 |
$116K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,939 |
1,810 |
$108K |
| D0274 |
Bitewings - four radiographic images |
5,919 |
5,918 |
$95K |
| D0120 |
Periodic oral evaluation - established patient |
5,940 |
5,938 |
$95K |
| D1351 |
Sealant - per tooth |
2,889 |
847 |
$94K |
| D0220 |
Intraoral - periapical first radiographic image |
9,425 |
9,403 |
$76K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,629 |
7,615 |
$68K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,581 |
3,578 |
$61K |
| D1120 |
Prophylaxis - child |
2,133 |
2,131 |
$58K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,558 |
1,150 |
$50K |
| D2954 |
|
536 |
475 |
$47K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
718 |
609 |
$42K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,343 |
3,343 |
$33K |
| D2335 |
|
251 |
221 |
$22K |
| D0272 |
Bitewings - two radiographic images |
1,617 |
1,617 |
$16K |
| D5110 |
|
57 |
57 |
$14K |
| D2332 |
|
233 |
179 |
$13K |
| D3320 |
|
70 |
68 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
574 |
572 |
$11K |
| D2791 |
|
41 |
41 |
$10K |
| D2330 |
|
229 |
181 |
$8K |
| D5213 |
|
12 |
12 |
$3K |
| D4341 |
|
73 |
40 |
$3K |
| D2331 |
|
44 |
37 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
171 |
169 |
$2K |
| D2160 |
|
20 |
16 |
$931.20 |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
18 |
12 |
$844.39 |
| D1999 |
|
15 |
15 |
$750.00 |
| D9110 |
|
37 |
37 |
$551.84 |