| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
4,370 |
4,345 |
$242K |
| D2740 |
Crown - porcelain/ceramic |
256 |
153 |
$185K |
| D0274 |
Bitewings - four radiographic images |
4,560 |
4,543 |
$168K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
1,140 |
734 |
$165K |
| D0120 |
Periodic oral evaluation - established patient |
4,486 |
4,464 |
$112K |
| D0140 |
Limited oral evaluation - problem focused |
2,593 |
2,573 |
$105K |
| D0220 |
Intraoral - periapical first radiographic image |
6,329 |
6,115 |
$100K |
| D1120 |
Prophylaxis - child |
1,902 |
1,898 |
$100K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,158 |
2,147 |
$95K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,129 |
491 |
$89K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,785 |
2,779 |
$84K |
| D1351 |
Sealant - per tooth |
1,698 |
506 |
$70K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,755 |
3,799 |
$66K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
498 |
350 |
$44K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
430 |
220 |
$26K |
| D0272 |
Bitewings - two radiographic images |
836 |
828 |
$25K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
123 |
97 |
$11K |
| D2950 |
|
47 |
41 |
$7K |
| D2335 |
|
16 |
14 |
$2K |
| D3120 |
|
39 |
28 |
$1K |
| D0270 |
|
14 |
14 |
$205.00 |