| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
5,411 |
5,013 |
$63K |
| D0120 |
Periodic oral evaluation - established patient |
5,583 |
5,194 |
$49K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,418 |
935 |
$38K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
1,600 |
788 |
$35K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,946 |
2,699 |
$33K |
| D0210 |
Intraoral - complete series of radiographic images |
1,450 |
1,444 |
$32K |
| D1120 |
Prophylaxis - child |
2,955 |
2,739 |
$32K |
| D2750 |
|
196 |
163 |
$32K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,079 |
2,822 |
$22K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
822 |
582 |
$20K |
| D0330 |
Panoramic radiographic image |
3,095 |
2,756 |
$19K |
| D0140 |
Limited oral evaluation - problem focused |
1,941 |
1,719 |
$19K |
| D0274 |
Bitewings - four radiographic images |
5,465 |
4,922 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
8,006 |
7,184 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,288 |
6,508 |
$9K |
| D2954 |
|
164 |
135 |
$5K |
| D2394 |
|
164 |
124 |
$5K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
29 |
24 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
108 |
76 |
$2K |
| D1206 |
Topical application of fluoride varnish |
132 |
126 |
$940.00 |
| D9110 |
|
79 |
79 |
$590.00 |
| D1351 |
Sealant - per tooth |
79 |
24 |
$500.00 |