| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
6,498 |
6,492 |
$256K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
3,103 |
1,854 |
$162K |
| D0210 |
Intraoral - complete series of radiographic images |
3,123 |
3,103 |
$123K |
| D0120 |
Periodic oral evaluation - established patient |
5,251 |
5,246 |
$110K |
| D0274 |
Bitewings - four radiographic images |
4,154 |
4,153 |
$86K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,120 |
2,119 |
$51K |
| D0220 |
Intraoral - periapical first radiographic image |
5,890 |
5,812 |
$48K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
759 |
592 |
$44K |
| D7140 |
Extraction, erupted tooth or exposed root |
572 |
399 |
$28K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,385 |
4,366 |
$21K |
| D1120 |
Prophylaxis - child |
506 |
506 |
$15K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
31 |
24 |
$12K |
| D0140 |
Limited oral evaluation - problem focused |
876 |
870 |
$10K |
| D9110 |
|
373 |
362 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
248 |
248 |
$3K |
| D2954 |
|
26 |
24 |
$2K |
| D2140 |
|
42 |
29 |
$2K |
| D2330 |
|
15 |
14 |
$872.73 |
| D1206 |
Topical application of fluoride varnish |
28 |
28 |
$75.00 |
| D1330 |
|
45 |
45 |
$0.00 |