| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
4,281 |
4,164 |
$45K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,925 |
931 |
$40K |
| D0120 |
Periodic oral evaluation - established patient |
3,633 |
3,568 |
$28K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,006 |
475 |
$24K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,141 |
2,074 |
$19K |
| D0330 |
Panoramic radiographic image |
1,863 |
1,790 |
$12K |
| D0274 |
Bitewings - four radiographic images |
3,273 |
3,200 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
644 |
332 |
$12K |
| D0140 |
Limited oral evaluation - problem focused |
896 |
865 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
3,298 |
3,217 |
$5K |
| D2332 |
|
163 |
67 |
$5K |
| D2740 |
Crown - porcelain/ceramic |
24 |
14 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,032 |
2,387 |
$5K |
| D1120 |
Prophylaxis - child |
419 |
408 |
$3K |
| D0160 |
|
608 |
589 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
109 |
107 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
100 |
65 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
381 |
371 |
$1K |
| D2950 |
|
40 |
28 |
$880.00 |
| D2331 |
|
25 |
12 |
$207.50 |
| D9430 |
|
150 |
137 |
$138.50 |