| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
6,181 |
6,180 |
$212K |
| D0274 |
Bitewings - four radiographic images |
6,465 |
6,464 |
$116K |
| D6010 |
|
94 |
18 |
$94K |
| D0120 |
Periodic oral evaluation - established patient |
4,404 |
4,403 |
$87K |
| D0220 |
Intraoral - periapical first radiographic image |
8,609 |
8,577 |
$75K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,365 |
3,365 |
$67K |
| D0230 |
Intraoral - periapical each additional radiographic image |
8,046 |
8,039 |
$38K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
530 |
392 |
$36K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,265 |
3,265 |
$30K |
| D1120 |
Prophylaxis - child |
933 |
933 |
$29K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
555 |
364 |
$22K |
| D0210 |
Intraoral - complete series of radiographic images |
2,337 |
2,331 |
$13K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
43 |
24 |
$13K |
| D2954 |
|
92 |
70 |
$9K |
| D0330 |
Panoramic radiographic image |
248 |
248 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
491 |
482 |
$5K |
| D1351 |
Sealant - per tooth |
53 |
33 |
$5K |
| D0272 |
Bitewings - two radiographic images |
263 |
263 |
$3K |
| D3320 |
|
13 |
12 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
13 |
12 |
$596.20 |
| D9310 |
|
13 |
13 |
$542.73 |
| D1330 |
|
12 |
12 |
$0.00 |
| D1999 |
|
1,160 |
1,071 |
$0.00 |