| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,096 |
2,095 |
$77K |
| D0120 |
Periodic oral evaluation - established patient |
2,674 |
2,674 |
$75K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
723 |
328 |
$51K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
100 |
75 |
$47K |
| D0330 |
Panoramic radiographic image |
939 |
939 |
$36K |
| D0274 |
Bitewings - four radiographic images |
2,111 |
2,111 |
$30K |
| D1120 |
Prophylaxis - child |
750 |
750 |
$24K |
| D0220 |
Intraoral - periapical first radiographic image |
3,831 |
3,724 |
$20K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
325 |
165 |
$19K |
| D1206 |
Topical application of fluoride varnish |
639 |
639 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,977 |
2,933 |
$13K |
| D0140 |
Limited oral evaluation - problem focused |
626 |
619 |
$13K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
120 |
81 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
171 |
171 |
$6K |
| D2950 |
|
103 |
89 |
$6K |
| D1351 |
Sealant - per tooth |
197 |
36 |
$4K |
| D2335 |
|
44 |
25 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
163 |
163 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
14 |
$630.00 |
| D0272 |
Bitewings - two radiographic images |
51 |
51 |
$432.00 |
| D1330 |
|
330 |
324 |
$0.00 |