| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
4,800 |
4,800 |
$166K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,426 |
1,622 |
$122K |
| D0210 |
Intraoral - complete series of radiographic images |
1,979 |
1,979 |
$69K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,512 |
3,512 |
$63K |
| D0274 |
Bitewings - four radiographic images |
3,390 |
3,390 |
$59K |
| D0120 |
Periodic oral evaluation - established patient |
2,349 |
2,349 |
$41K |
| D0220 |
Intraoral - periapical first radiographic image |
3,442 |
3,414 |
$28K |
| D1206 |
Topical application of fluoride varnish |
1,529 |
1,529 |
$27K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,717 |
3,692 |
$27K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
397 |
336 |
$25K |
| D1120 |
Prophylaxis - child |
696 |
696 |
$18K |
| D2753 |
|
29 |
25 |
$14K |
| D0140 |
Limited oral evaluation - problem focused |
1,223 |
1,194 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
682 |
682 |
$6K |
| D9920 |
|
263 |
243 |
$5K |
| D9430 |
|
200 |
180 |
$3K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
14 |
12 |
$756.00 |