| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,056 |
3,050 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
817 |
690 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
3,663 |
3,663 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,531 |
1,531 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
3,276 |
3,251 |
$2K |
| D0274 |
Bitewings - four radiographic images |
2,136 |
2,136 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,371 |
1,011 |
$2K |
| D1120 |
Prophylaxis - child |
1,344 |
1,344 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
1,382 |
1,379 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
57 |
57 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
82 |
42 |
$867.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,205 |
1,203 |
$576.81 |
| D1206 |
Topical application of fluoride varnish |
635 |
635 |
$363.02 |
| D0272 |
Bitewings - two radiographic images |
627 |
627 |
$278.19 |
| D1208 |
Topical application of fluoride, excluding varnish |
997 |
997 |
$250.96 |
| D2330 |
|
93 |
71 |
$124.02 |
| D2140 |
|
25 |
24 |
$117.55 |
| D2331 |
|
30 |
25 |
$40.81 |
| D0270 |
|
13 |
13 |
$10.00 |
| D0145 |
Oral evaluation for a patient under three years of age |
37 |
37 |
$0.00 |
| D1999 |
|
33 |
33 |
$0.00 |
| D1351 |
Sealant - per tooth |
50 |
14 |
$0.00 |
| D9995 |
|
17 |
17 |
$0.00 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
12 |
12 |
$0.00 |