| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
4,406 |
4,406 |
$231K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,798 |
998 |
$165K |
| D0120 |
Periodic oral evaluation - established patient |
5,748 |
5,745 |
$153K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
242 |
200 |
$134K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
803 |
513 |
$88K |
| D0210 |
Intraoral - complete series of radiographic images |
1,560 |
1,558 |
$75K |
| D0274 |
Bitewings - four radiographic images |
1,602 |
1,602 |
$42K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
464 |
305 |
$29K |
| D1120 |
Prophylaxis - child |
392 |
392 |
$16K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,131 |
1,131 |
$16K |
| D2954 |
|
82 |
73 |
$11K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
28 |
26 |
$11K |
| D2394 |
|
55 |
42 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
93 |
53 |
$6K |
| D0330 |
Panoramic radiographic image |
133 |
133 |
$4K |
| D2335 |
|
27 |
14 |
$4K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
16 |
13 |
$2K |
| D4341 |
|
34 |
12 |
$2K |
| D4910 |
|
29 |
29 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
51 |
51 |
$632.41 |
| D0140 |
Limited oral evaluation - problem focused |
37 |
37 |
$508.20 |