| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
5,010 |
5,008 |
$299K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,662 |
1,274 |
$162K |
| D0120 |
Periodic oral evaluation - established patient |
4,773 |
4,771 |
$143K |
| D0274 |
Bitewings - four radiographic images |
2,298 |
2,298 |
$64K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
561 |
478 |
$37K |
| D0330 |
Panoramic radiographic image |
634 |
633 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
629 |
629 |
$19K |
| D2740 |
Crown - porcelain/ceramic |
16 |
13 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,150 |
899 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
665 |
661 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
231 |
231 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
445 |
445 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
417 |
408 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
32 |
28 |
$4K |
| D1120 |
Prophylaxis - child |
56 |
56 |
$2K |
| D2331 |
|
12 |
12 |
$942.26 |
| D7140 |
Extraction, erupted tooth or exposed root |
13 |
12 |
$692.25 |
| D1999 |
|
72 |
62 |
$0.00 |