| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,818 |
2,793 |
$186K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
1,417 |
797 |
$166K |
| D1351 |
Sealant - per tooth |
2,211 |
528 |
$83K |
| D1110 |
Prophylaxis - adult |
917 |
908 |
$78K |
| D1120 |
Prophylaxis - child |
1,235 |
1,224 |
$62K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
131 |
117 |
$62K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
819 |
595 |
$55K |
| D0120 |
Periodic oral evaluation - established patient |
709 |
707 |
$54K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
927 |
606 |
$50K |
| D0210 |
Intraoral - complete series of radiographic images |
967 |
955 |
$46K |
| D7140 |
Extraction, erupted tooth or exposed root |
682 |
399 |
$39K |
| D0274 |
Bitewings - four radiographic images |
1,791 |
1,781 |
$37K |
| D0350 |
|
3,325 |
1,650 |
$32K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,554 |
2,436 |
$31K |
| D4341 |
|
415 |
139 |
$29K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,105 |
1,092 |
$16K |
| D1206 |
Topical application of fluoride varnish |
898 |
897 |
$14K |
| D9430 |
|
420 |
412 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
1,081 |
1,063 |
$13K |
| D2954 |
|
102 |
93 |
$11K |
| D2330 |
|
51 |
37 |
$4K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
41 |
31 |
$3K |
| D4910 |
|
29 |
29 |
$2K |
| D2140 |
|
36 |
28 |
$2K |
| D1310 |
|
26 |
26 |
$1K |
| D0330 |
Panoramic radiographic image |
31 |
30 |
$930.00 |
| D9993 |
|
26 |
26 |
$0.00 |