| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,645 |
2,630 |
$105K |
| D0120 |
Periodic oral evaluation - established patient |
2,989 |
2,978 |
$69K |
| D0210 |
Intraoral - complete series of radiographic images |
1,109 |
1,100 |
$50K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
586 |
304 |
$45K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,190 |
1,184 |
$38K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
620 |
251 |
$37K |
| D1120 |
Prophylaxis - child |
859 |
859 |
$35K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,165 |
1,164 |
$29K |
| D0274 |
Bitewings - four radiographic images |
851 |
847 |
$24K |
| D2740 |
Crown - porcelain/ceramic |
17 |
12 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
393 |
384 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
833 |
799 |
$8K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
145 |
41 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
43 |
14 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
306 |
222 |
$1K |
| D0272 |
Bitewings - two radiographic images |
24 |
24 |
$587.66 |