| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
4,998 |
4,797 |
$263K |
| D2740 |
Crown - porcelain/ceramic |
364 |
231 |
$257K |
| D0274 |
Bitewings - four radiographic images |
5,268 |
5,046 |
$180K |
| D0120 |
Periodic oral evaluation - established patient |
5,194 |
5,002 |
$120K |
| D0330 |
Panoramic radiographic image |
2,353 |
2,230 |
$91K |
| D0220 |
Intraoral - periapical first radiographic image |
5,376 |
5,002 |
$80K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
593 |
226 |
$70K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
842 |
555 |
$69K |
| D0140 |
Limited oral evaluation - problem focused |
1,622 |
1,520 |
$62K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,481 |
3,637 |
$55K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,892 |
1,848 |
$55K |
| D1120 |
Prophylaxis - child |
1,005 |
972 |
$47K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
581 |
339 |
$47K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,095 |
1,038 |
$47K |
| D2950 |
|
181 |
135 |
$28K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
410 |
244 |
$26K |
| D1351 |
Sealant - per tooth |
261 |
71 |
$10K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
17 |
15 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
80 |
55 |
$6K |
| D2332 |
|
51 |
27 |
$5K |
| D2394 |
|
34 |
30 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
35 |
29 |
$2K |
| D1206 |
Topical application of fluoride varnish |
18 |
18 |
$702.00 |
| D1330 |
|
19 |
19 |
$266.00 |
| D1999 |
|
61 |
57 |
$0.00 |