| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
6,494 |
6,494 |
$334K |
| D0120 |
Periodic oral evaluation - established patient |
7,186 |
7,186 |
$194K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,186 |
1,024 |
$128K |
| D0274 |
Bitewings - four radiographic images |
3,204 |
3,204 |
$105K |
| D0330 |
Panoramic radiographic image |
751 |
751 |
$31K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
438 |
346 |
$30K |
| D0220 |
Intraoral - periapical first radiographic image |
1,942 |
1,929 |
$29K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,503 |
1,503 |
$27K |
| D0210 |
Intraoral - complete series of radiographic images |
588 |
587 |
$26K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
216 |
207 |
$24K |
| D1120 |
Prophylaxis - child |
484 |
484 |
$20K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,627 |
1,567 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
520 |
520 |
$16K |
| D0140 |
Limited oral evaluation - problem focused |
383 |
376 |
$9K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
61 |
56 |
$7K |
| D2954 |
|
14 |
14 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
12 |
12 |
$1K |
| D1206 |
Topical application of fluoride varnish |
29 |
29 |
$700.04 |
| D9110 |
|
12 |
12 |
$334.30 |
| D1320 |
|
16 |
16 |
$104.00 |
| D1999 |
|
29 |
27 |
$0.00 |