| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,508 |
2,508 |
$98K |
| D0120 |
Periodic oral evaluation - established patient |
4,343 |
4,343 |
$83K |
| D0274 |
Bitewings - four radiographic images |
3,579 |
3,579 |
$68K |
| D1120 |
Prophylaxis - child |
2,308 |
2,308 |
$67K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
994 |
657 |
$61K |
| D0220 |
Intraoral - periapical first radiographic image |
4,291 |
4,281 |
$36K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,126 |
2,126 |
$23K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,044 |
4,044 |
$20K |
| D7140 |
Extraction, erupted tooth or exposed root |
563 |
300 |
$19K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
41 |
25 |
$17K |
| D1351 |
Sealant - per tooth |
382 |
148 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
571 |
571 |
$12K |
| D1206 |
Topical application of fluoride varnish |
608 |
608 |
$11K |
| D4342 |
|
457 |
200 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
236 |
153 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
328 |
328 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
64 |
53 |
$5K |
| D8670 |
Periodic orthodontic treatment visit |
14 |
14 |
$3K |
| D2954 |
|
21 |
13 |
$2K |
| D0330 |
Panoramic radiographic image |
77 |
77 |
$2K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
22 |
15 |
$1K |
| D0272 |
Bitewings - two radiographic images |
52 |
52 |
$608.26 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$125.64 |