| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,716 |
3,715 |
$157K |
| D0120 |
Periodic oral evaluation - established patient |
6,243 |
6,243 |
$137K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,285 |
902 |
$87K |
| D1120 |
Prophylaxis - child |
2,348 |
2,348 |
$77K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,226 |
5,222 |
$76K |
| D0220 |
Intraoral - periapical first radiographic image |
5,995 |
5,988 |
$62K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,987 |
2,987 |
$35K |
| D0274 |
Bitewings - four radiographic images |
1,691 |
1,691 |
$34K |
| D0272 |
Bitewings - two radiographic images |
2,379 |
2,379 |
$30K |
| D0330 |
Panoramic radiographic image |
1,149 |
1,149 |
$30K |
| D0210 |
Intraoral - complete series of radiographic images |
3,637 |
3,635 |
$28K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
736 |
736 |
$17K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
431 |
294 |
$16K |
| D9310 |
|
186 |
186 |
$8K |
| D1206 |
Topical application of fluoride varnish |
335 |
335 |
$8K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
87 |
67 |
$6K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
14 |
13 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
419 |
418 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
92 |
69 |
$4K |
| D2954 |
|
28 |
27 |
$3K |
| D8660 |
|
39 |
39 |
$1K |
| D0340 |
|
24 |
24 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
12 |
12 |
$669.42 |
| D0350 |
|
29 |
27 |
$291.95 |
| D0270 |
|
18 |
18 |
$123.10 |
| D1999 |
|
112 |
111 |
$0.00 |