| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,626 |
1,599 |
$56K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
787 |
414 |
$47K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
626 |
111 |
$42K |
| D1351 |
Sealant - per tooth |
1,767 |
310 |
$42K |
| D0330 |
Panoramic radiographic image |
766 |
749 |
$31K |
| D0272 |
Bitewings - two radiographic images |
1,739 |
1,708 |
$27K |
| D0120 |
Periodic oral evaluation - established patient |
1,263 |
1,247 |
$25K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
491 |
266 |
$24K |
| D7140 |
Extraction, erupted tooth or exposed root |
322 |
122 |
$21K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
49 |
32 |
$20K |
| D1120 |
Prophylaxis - child |
488 |
479 |
$15K |
| D1208 |
Topical application of fluoride, excluding varnish |
789 |
778 |
$14K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
208 |
126 |
$14K |
| D2332 |
|
204 |
103 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
611 |
593 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
645 |
616 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
403 |
275 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
42 |
41 |
$3K |
| D1206 |
Topical application of fluoride varnish |
113 |
112 |
$2K |
| D0274 |
Bitewings - four radiographic images |
65 |
65 |
$2K |
| D2330 |
|
16 |
12 |
$755.00 |
| D1310 |
|
48 |
46 |
$397.07 |
| D1999 |
|
55 |
50 |
$275.00 |
| D1330 |
|
36 |
34 |
$242.60 |