| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
4,807 |
4,806 |
$166K |
| D0120 |
Periodic oral evaluation - established patient |
5,410 |
5,403 |
$108K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
215 |
150 |
$91K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,245 |
806 |
$79K |
| D0274 |
Bitewings - four radiographic images |
4,097 |
4,097 |
$77K |
| D0220 |
Intraoral - periapical first radiographic image |
6,792 |
6,646 |
$63K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,458 |
6,311 |
$51K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
867 |
487 |
$36K |
| D9310 |
|
739 |
729 |
$34K |
| D2954 |
|
241 |
180 |
$26K |
| D0330 |
Panoramic radiographic image |
775 |
773 |
$18K |
| D0210 |
Intraoral - complete series of radiographic images |
2,482 |
2,351 |
$15K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
132 |
101 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
904 |
904 |
$11K |
| D3320 |
|
49 |
38 |
$9K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
12 |
12 |
$4K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
23 |
18 |
$2K |
| D1120 |
Prophylaxis - child |
15 |
15 |
$437.27 |
| D0140 |
Limited oral evaluation - problem focused |
24 |
24 |
$229.57 |
| D1999 |
|
13 |
13 |
$0.00 |