| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,348 |
1,273 |
$75K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
623 |
356 |
$54K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
678 |
365 |
$49K |
| D0274 |
Bitewings - four radiographic images |
1,272 |
1,222 |
$48K |
| D0120 |
Periodic oral evaluation - established patient |
1,706 |
1,645 |
$44K |
| D1120 |
Prophylaxis - child |
625 |
611 |
$31K |
| D1208 |
Topical application of fluoride, excluding varnish |
947 |
928 |
$28K |
| D2740 |
Crown - porcelain/ceramic |
39 |
26 |
$26K |
| D0140 |
Limited oral evaluation - problem focused |
644 |
612 |
$25K |
| D0220 |
Intraoral - periapical first radiographic image |
909 |
866 |
$14K |
| D1351 |
Sealant - per tooth |
282 |
92 |
$12K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
78 |
55 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
161 |
157 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
79 |
77 |
$6K |
| D8670 |
Periodic orthodontic treatment visit |
18 |
18 |
$5K |
| D2950 |
|
30 |
25 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
168 |
124 |
$2K |
| D0272 |
Bitewings - two radiographic images |
66 |
65 |
$2K |