| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,828 |
1,812 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
770 |
764 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
2,900 |
2,824 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
748 |
742 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,677 |
1,607 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
389 |
305 |
$870.00 |
| D0274 |
Bitewings - four radiographic images |
739 |
724 |
$855.00 |
| D0140 |
Limited oral evaluation - problem focused |
1,283 |
1,247 |
$540.00 |
| D0120 |
Periodic oral evaluation - established patient |
1,549 |
1,524 |
$475.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
36 |
24 |
$191.64 |
| D1120 |
Prophylaxis - child |
105 |
104 |
$92.50 |
| D1208 |
Topical application of fluoride, excluding varnish |
135 |
135 |
$85.00 |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
384 |
291 |
$62.00 |
| D0330 |
Panoramic radiographic image |
43 |
41 |
$47.25 |
| D0272 |
Bitewings - two radiographic images |
25 |
24 |
$10.00 |
| D0270 |
|
50 |
49 |
$0.00 |
| D3221 |
|
30 |
29 |
$0.00 |
| D2740 |
Crown - porcelain/ceramic |
13 |
12 |
$0.00 |
| D1330 |
|
475 |
445 |
$0.00 |
| D1351 |
Sealant - per tooth |
38 |
13 |
$0.00 |