| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,348 |
1,344 |
$107K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,610 |
1,604 |
$106K |
| D0210 |
Intraoral - complete series of radiographic images |
1,449 |
1,443 |
$69K |
| D0330 |
Panoramic radiographic image |
1,607 |
1,600 |
$48K |
| D0120 |
Periodic oral evaluation - established patient |
591 |
590 |
$48K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
379 |
231 |
$44K |
| D1120 |
Prophylaxis - child |
775 |
773 |
$36K |
| D1206 |
Topical application of fluoride varnish |
2,042 |
2,036 |
$31K |
| D4341 |
|
385 |
102 |
$27K |
| D1351 |
Sealant - per tooth |
712 |
141 |
$26K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,705 |
1,125 |
$24K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
295 |
191 |
$20K |
| D2740 |
Crown - porcelain/ceramic |
42 |
31 |
$19K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
213 |
137 |
$17K |
| D0274 |
Bitewings - four radiographic images |
750 |
747 |
$16K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
32 |
29 |
$15K |
| D3320 |
|
17 |
15 |
$6K |
| D0350 |
|
559 |
224 |
$5K |
| D2394 |
|
31 |
24 |
$3K |
| D9110 |
|
31 |
26 |
$2K |
| D2952 |
|
16 |
15 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
113 |
112 |
$1K |
| D4910 |
|
13 |
13 |
$1K |
| D9430 |
|
27 |
27 |
$864.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$116.00 |