| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,466 |
1,446 |
$64K |
| D1206 |
Topical application of fluoride varnish |
1,199 |
1,171 |
$36K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
448 |
278 |
$27K |
| D0120 |
Periodic oral evaluation - established patient |
1,068 |
1,039 |
$25K |
| D0140 |
Limited oral evaluation - problem focused |
496 |
488 |
$21K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
296 |
172 |
$15K |
| D2740 |
Crown - porcelain/ceramic |
34 |
25 |
$14K |
| D0210 |
Intraoral - complete series of radiographic images |
251 |
248 |
$11K |
| D0274 |
Bitewings - four radiographic images |
758 |
736 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
1,303 |
1,266 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,025 |
978 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
225 |
225 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
176 |
174 |
$4K |
| D0330 |
Panoramic radiographic image |
93 |
92 |
$4K |
| D2950 |
|
58 |
40 |
$2K |
| D1120 |
Prophylaxis - child |
67 |
59 |
$2K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
21 |
17 |
$2K |
| D0272 |
Bitewings - two radiographic images |
30 |
30 |
$290.00 |