| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,659 |
3,645 |
$158K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,319 |
814 |
$108K |
| D0120 |
Periodic oral evaluation - established patient |
3,743 |
3,732 |
$99K |
| D0210 |
Intraoral - complete series of radiographic images |
1,199 |
1,185 |
$66K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,351 |
1,336 |
$46K |
| D0140 |
Limited oral evaluation - problem focused |
1,363 |
1,296 |
$45K |
| D1120 |
Prophylaxis - child |
1,144 |
1,141 |
$44K |
| D0274 |
Bitewings - four radiographic images |
1,384 |
1,375 |
$39K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
333 |
256 |
$34K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,294 |
1,286 |
$29K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
335 |
190 |
$28K |
| D7140 |
Extraction, erupted tooth or exposed root |
416 |
203 |
$23K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
329 |
242 |
$22K |
| D0220 |
Intraoral - periapical first radiographic image |
1,381 |
1,352 |
$15K |
| D2331 |
|
63 |
38 |
$4K |
| D2394 |
|
30 |
25 |
$4K |
| D0272 |
Bitewings - two radiographic images |
124 |
124 |
$3K |
| D4342 |
|
29 |
12 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
312 |
240 |
$3K |
| D1206 |
Topical application of fluoride varnish |
54 |
54 |
$1K |
| D1351 |
Sealant - per tooth |
30 |
12 |
$870.00 |