| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
4,517 |
4,504 |
$387K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
4,435 |
4,421 |
$281K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
2,026 |
903 |
$237K |
| D0120 |
Periodic oral evaluation - established patient |
3,229 |
3,210 |
$204K |
| D0230 |
Intraoral - periapical each additional radiographic image |
48,674 |
7,556 |
$192K |
| D0274 |
Bitewings - four radiographic images |
6,081 |
6,065 |
$126K |
| D1120 |
Prophylaxis - child |
1,994 |
1,983 |
$83K |
| D1206 |
Topical application of fluoride varnish |
4,937 |
4,917 |
$80K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,021 |
567 |
$66K |
| D1351 |
Sealant - per tooth |
1,498 |
314 |
$52K |
| D0350 |
|
5,423 |
1,491 |
$50K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
523 |
290 |
$41K |
| D1320 |
|
1,178 |
1,171 |
$20K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
289 |
147 |
$19K |
| D4341 |
|
294 |
78 |
$18K |
| D4910 |
|
232 |
229 |
$18K |
| D2160 |
|
186 |
95 |
$15K |
| D9430 |
|
392 |
389 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
561 |
551 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
114 |
63 |
$6K |
| D2332 |
|
64 |
31 |
$5K |
| D2331 |
|
52 |
25 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
295 |
291 |
$3K |
| D0272 |
Bitewings - two radiographic images |
287 |
287 |
$3K |
| D0330 |
Panoramic radiographic image |
84 |
84 |
$3K |
| D9993 |
|
12 |
12 |
$780.00 |
| D1310 |
|
12 |
12 |
$552.00 |
| D0270 |
|
17 |
17 |
$85.00 |