| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,814 |
1,810 |
$161K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,912 |
1,910 |
$126K |
| D0120 |
Periodic oral evaluation - established patient |
1,015 |
1,010 |
$74K |
| D2740 |
Crown - porcelain/ceramic |
135 |
114 |
$69K |
| D0210 |
Intraoral - complete series of radiographic images |
1,399 |
1,396 |
$68K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
959 |
461 |
$53K |
| D0350 |
|
5,356 |
1,455 |
$51K |
| D9430 |
|
1,254 |
1,237 |
$40K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,757 |
2,749 |
$39K |
| D1120 |
Prophylaxis - child |
796 |
793 |
$35K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
269 |
220 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
1,371 |
1,354 |
$16K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,600 |
1,157 |
$15K |
| D0274 |
Bitewings - four radiographic images |
500 |
500 |
$11K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
71 |
36 |
$8K |
| D4910 |
|
37 |
37 |
$3K |
| D0330 |
Panoramic radiographic image |
70 |
70 |
$2K |
| D1351 |
Sealant - per tooth |
54 |
13 |
$2K |
| D1320 |
|
25 |
25 |
$347.50 |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$267.50 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$130.00 |