| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,201 |
1,199 |
$41K |
| D0140 |
Limited oral evaluation - problem focused |
1,000 |
995 |
$38K |
| D0120 |
Periodic oral evaluation - established patient |
1,512 |
1,512 |
$35K |
| D1120 |
Prophylaxis - child |
895 |
895 |
$29K |
| D1206 |
Topical application of fluoride varnish |
1,214 |
1,213 |
$21K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
422 |
225 |
$21K |
| D0210 |
Intraoral - complete series of radiographic images |
473 |
473 |
$16K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
43 |
38 |
$16K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,997 |
1,992 |
$15K |
| D1351 |
Sealant - per tooth |
636 |
107 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
2,658 |
2,552 |
$12K |
| D4355 |
|
120 |
120 |
$8K |
| D0274 |
Bitewings - four radiographic images |
646 |
645 |
$6K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
138 |
77 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
168 |
168 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
45 |
13 |
$2K |
| D0601 |
|
137 |
137 |
$1K |
| D2950 |
|
15 |
13 |
$750.00 |
| D0602 |
|
38 |
38 |
$380.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$150.00 |
| D0273 |
|
12 |
12 |
$144.00 |