| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,253 |
2,250 |
$92K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
965 |
674 |
$67K |
| D0274 |
Bitewings - four radiographic images |
2,710 |
2,708 |
$57K |
| D0220 |
Intraoral - periapical first radiographic image |
3,432 |
3,381 |
$33K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,314 |
1,312 |
$31K |
| D0120 |
Periodic oral evaluation - established patient |
1,416 |
1,414 |
$31K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,780 |
2,774 |
$26K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
183 |
142 |
$15K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
104 |
85 |
$7K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
17 |
14 |
$7K |
| D9110 |
|
352 |
335 |
$6K |
| D1120 |
Prophylaxis - child |
172 |
171 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
372 |
370 |
$4K |
| D0270 |
|
403 |
398 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
1,360 |
1,309 |
$3K |
| D2954 |
|
15 |
13 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
21 |
12 |
$863.00 |
| D0140 |
Limited oral evaluation - problem focused |
71 |
70 |
$719.09 |
| D9430 |
|
16 |
16 |
$239.10 |