| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
9,063 |
9,062 |
$309K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
697 |
606 |
$265K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,090 |
2,419 |
$175K |
| D1351 |
Sealant - per tooth |
3,349 |
1,086 |
$149K |
| D0274 |
Bitewings - four radiographic images |
7,959 |
7,959 |
$146K |
| D0120 |
Periodic oral evaluation - established patient |
7,267 |
7,267 |
$145K |
| D7140 |
Extraction, erupted tooth or exposed root |
3,527 |
2,481 |
$132K |
| D0220 |
Intraoral - periapical first radiographic image |
13,011 |
12,993 |
$131K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
5,202 |
5,202 |
$107K |
| D0230 |
Intraoral - periapical each additional radiographic image |
10,653 |
10,651 |
$100K |
| D2954 |
|
910 |
812 |
$82K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,236 |
1,712 |
$81K |
| D1120 |
Prophylaxis - child |
2,416 |
2,416 |
$76K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,080 |
959 |
$71K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,172 |
4,172 |
$48K |
| D2332 |
|
563 |
471 |
$38K |
| D0272 |
Bitewings - two radiographic images |
1,973 |
1,973 |
$24K |
| D0210 |
Intraoral - complete series of radiographic images |
1,207 |
1,207 |
$21K |
| D2330 |
|
399 |
285 |
$14K |
| D3320 |
|
78 |
78 |
$13K |
| D2331 |
|
160 |
122 |
$10K |
| D4341 |
|
117 |
69 |
$5K |
| D2335 |
|
75 |
64 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
332 |
332 |
$3K |
| D9110 |
|
116 |
116 |
$2K |