| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,881 |
1,870 |
$24K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
195 |
152 |
$22K |
| D0140 |
Limited oral evaluation - problem focused |
995 |
973 |
$18K |
| D4341 |
|
427 |
268 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
526 |
522 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
2,298 |
2,247 |
$15K |
| D0274 |
Bitewings - four radiographic images |
803 |
791 |
$13K |
| D1206 |
Topical application of fluoride varnish |
994 |
985 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
98 |
66 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,782 |
1,283 |
$10K |
| D7140 |
Extraction, erupted tooth or exposed root |
479 |
263 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
471 |
468 |
$7K |
| D1120 |
Prophylaxis - child |
595 |
594 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
15 |
13 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,420 |
1,417 |
$4K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
110 |
70 |
$3K |
| D1351 |
Sealant - per tooth |
158 |
39 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$2K |
| D4355 |
|
102 |
102 |
$2K |
| D4910 |
|
187 |
187 |
$1K |
| D9310 |
|
41 |
40 |
$540.00 |
| D0272 |
Bitewings - two radiographic images |
73 |
73 |
$360.00 |
| D0191 |
|
107 |
107 |
$360.00 |
| D0240 |
|
65 |
34 |
$256.00 |
| D1330 |
|
3,201 |
3,150 |
$80.15 |
| D1310 |
|
858 |
851 |
$0.00 |
| D9986 |
|
1,590 |
1,548 |
$0.00 |