| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
5,625 |
5,625 |
$305K |
| D0120 |
Periodic oral evaluation - established patient |
6,679 |
6,679 |
$181K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,774 |
1,504 |
$178K |
| D2740 |
Crown - porcelain/ceramic |
190 |
156 |
$106K |
| D1120 |
Prophylaxis - child |
2,357 |
2,357 |
$100K |
| D0274 |
Bitewings - four radiographic images |
2,585 |
2,585 |
$71K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,019 |
2,019 |
$60K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,673 |
3,673 |
$51K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
808 |
685 |
$49K |
| D0330 |
Panoramic radiographic image |
1,001 |
1,001 |
$35K |
| D1351 |
Sealant - per tooth |
412 |
200 |
$30K |
| D0210 |
Intraoral - complete series of radiographic images |
1,135 |
1,132 |
$29K |
| D7140 |
Extraction, erupted tooth or exposed root |
332 |
255 |
$28K |
| D0220 |
Intraoral - periapical first radiographic image |
1,152 |
1,139 |
$15K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
88 |
81 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
412 |
410 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
309 |
308 |
$4K |
| D0272 |
Bitewings - two radiographic images |
223 |
223 |
$4K |
| D1206 |
Topical application of fluoride varnish |
84 |
84 |
$3K |
| D0251 |
|
124 |
123 |
$2K |
| D1999 |
|
292 |
268 |
$0.00 |