| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
4,148 |
4,148 |
$58K |
| D0120 |
Periodic oral evaluation - established patient |
3,384 |
3,383 |
$54K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,568 |
1,101 |
$40K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,215 |
2,215 |
$34K |
| D0210 |
Intraoral - complete series of radiographic images |
1,036 |
1,036 |
$27K |
| D1120 |
Prophylaxis - child |
1,271 |
1,271 |
$21K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
670 |
463 |
$18K |
| D0274 |
Bitewings - four radiographic images |
2,607 |
2,606 |
$11K |
| D1206 |
Topical application of fluoride varnish |
1,537 |
1,537 |
$8K |
| D0330 |
Panoramic radiographic image |
1,225 |
1,225 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
296 |
284 |
$4K |
| D2740 |
Crown - porcelain/ceramic |
16 |
15 |
$3K |
| D0603 |
|
315 |
315 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
522 |
522 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
869 |
843 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
51 |
40 |
$2K |
| D0272 |
Bitewings - two radiographic images |
250 |
250 |
$895.00 |
| D4341 |
|
29 |
12 |
$735.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
18 |
12 |
$576.00 |
| D2331 |
|
16 |
12 |
$440.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
65 |
64 |
$111.00 |