| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,996 |
1,996 |
$157K |
| D1120 |
Prophylaxis - child |
1,121 |
1,121 |
$79K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,212 |
681 |
$64K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
322 |
322 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
3,174 |
3,173 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
59 |
38 |
$5K |
| D0330 |
Panoramic radiographic image |
121 |
120 |
$5K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
39 |
12 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
26 |
26 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
127 |
126 |
$3K |
| D0274 |
Bitewings - four radiographic images |
2,057 |
2,057 |
$2K |
| D1351 |
Sealant - per tooth |
95 |
14 |
$382.45 |
| D0272 |
Bitewings - two radiographic images |
851 |
851 |
$158.70 |
| D1206 |
Topical application of fluoride varnish |
2,700 |
2,700 |
$111.90 |
| D0220 |
Intraoral - periapical first radiographic image |
1,254 |
1,230 |
$84.27 |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,694 |
728 |
$0.00 |
| D1999 |
|
434 |
373 |
$0.00 |