| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
5,520 |
5,520 |
$269K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,609 |
1,074 |
$211K |
| D0210 |
Intraoral - complete series of radiographic images |
1,659 |
1,659 |
$210K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,906 |
1,784 |
$155K |
| D0330 |
Panoramic radiographic image |
3,025 |
3,025 |
$112K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
961 |
603 |
$31K |
| D0140 |
Limited oral evaluation - problem focused |
566 |
559 |
$16K |
| D2394 |
|
62 |
39 |
$12K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
103 |
56 |
$11K |
| D4341 |
|
117 |
51 |
$8K |
| D4346 |
|
40 |
40 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,912 |
2,912 |
$5K |
| D0274 |
Bitewings - four radiographic images |
4,383 |
4,381 |
$2K |
| D1120 |
Prophylaxis - child |
24 |
24 |
$1K |
| D2331 |
|
36 |
24 |
$949.25 |
| D2330 |
|
41 |
28 |
$928.04 |
| D4910 |
|
14 |
14 |
$697.48 |
| D0120 |
Periodic oral evaluation - established patient |
1,919 |
1,917 |
$587.28 |
| D0220 |
Intraoral - periapical first radiographic image |
882 |
862 |
$235.58 |
| D1351 |
Sealant - per tooth |
405 |
59 |
$229.13 |
| D1208 |
Topical application of fluoride, excluding varnish |
1,036 |
1,036 |
$0.00 |