| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,297 |
2,296 |
$178K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,081 |
626 |
$144K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,466 |
1,515 |
$126K |
| D1120 |
Prophylaxis - child |
632 |
632 |
$42K |
| D2740 |
Crown - porcelain/ceramic |
83 |
63 |
$34K |
| D0210 |
Intraoral - complete series of radiographic images |
141 |
141 |
$17K |
| D0140 |
Limited oral evaluation - problem focused |
494 |
487 |
$14K |
| D0330 |
Panoramic radiographic image |
309 |
309 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
285 |
285 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
311 |
200 |
$5K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
42 |
28 |
$5K |
| D2394 |
|
20 |
12 |
$4K |
| D0274 |
Bitewings - four radiographic images |
2,502 |
2,501 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
2,438 |
2,396 |
$483.15 |
| D1351 |
Sealant - per tooth |
138 |
24 |
$333.28 |
| D0120 |
Periodic oral evaluation - established patient |
2,857 |
2,856 |
$291.99 |
| D0272 |
Bitewings - two radiographic images |
329 |
329 |
$190.77 |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,312 |
1,449 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
2,810 |
2,810 |
$0.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,042 |
924 |
$0.00 |