| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2750 |
|
281 |
225 |
$155K |
| D1110 |
Prophylaxis - adult |
1,042 |
1,042 |
$47K |
| D0120 |
Periodic oral evaluation - established patient |
1,554 |
1,554 |
$39K |
| D0140 |
Limited oral evaluation - problem focused |
722 |
682 |
$32K |
| D1120 |
Prophylaxis - child |
640 |
640 |
$29K |
| D1206 |
Topical application of fluoride varnish |
874 |
874 |
$27K |
| D2954 |
|
248 |
198 |
$24K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
307 |
177 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,708 |
1,633 |
$13K |
| D9110 |
|
447 |
429 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
2,226 |
2,053 |
$11K |
| D0274 |
Bitewings - four radiographic images |
819 |
819 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
381 |
381 |
$10K |
| D4341 |
|
81 |
32 |
$5K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
55 |
25 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
100 |
100 |
$4K |
| D0272 |
Bitewings - two radiographic images |
375 |
375 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
26 |
15 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
69 |
69 |
$2K |
| D4910 |
|
15 |
15 |
$1K |