| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,619 |
2,559 |
$89K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,084 |
481 |
$65K |
| D0120 |
Periodic oral evaluation - established patient |
3,361 |
3,281 |
$64K |
| D0210 |
Intraoral - complete series of radiographic images |
1,240 |
1,195 |
$46K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
509 |
192 |
$26K |
| D7140 |
Extraction, erupted tooth or exposed root |
370 |
208 |
$24K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
40 |
34 |
$23K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,945 |
780 |
$20K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
247 |
128 |
$16K |
| D9110 |
|
412 |
392 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
1,288 |
1,251 |
$10K |
| D0274 |
Bitewings - four radiographic images |
241 |
239 |
$6K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
47 |
26 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
75 |
74 |
$1K |
| D2335 |
|
15 |
12 |
$1K |
| D0272 |
Bitewings - two radiographic images |
43 |
43 |
$688.00 |
| D1120 |
Prophylaxis - child |
13 |
13 |
$343.95 |