| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,520 |
2,503 |
$82K |
| D0210 |
Intraoral - complete series of radiographic images |
1,449 |
1,441 |
$68K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
554 |
377 |
$51K |
| D0120 |
Periodic oral evaluation - established patient |
2,463 |
2,452 |
$48K |
| D0140 |
Limited oral evaluation - problem focused |
2,150 |
2,088 |
$43K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,265 |
1,257 |
$37K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
384 |
307 |
$37K |
| D1120 |
Prophylaxis - child |
866 |
864 |
$35K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
406 |
199 |
$34K |
| D0274 |
Bitewings - four radiographic images |
1,425 |
1,419 |
$31K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,018 |
1,015 |
$25K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,822 |
1,929 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
2,392 |
2,347 |
$18K |
| D2790 |
|
21 |
17 |
$13K |
| D4355 |
|
221 |
220 |
$11K |
| D7140 |
Extraction, erupted tooth or exposed root |
142 |
89 |
$10K |
| D2740 |
Crown - porcelain/ceramic |
16 |
14 |
$8K |
| D2950 |
|
24 |
16 |
$4K |
| D1351 |
Sealant - per tooth |
98 |
28 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
28 |
25 |
$2K |
| D2394 |
|
25 |
25 |
$2K |
| D0272 |
Bitewings - two radiographic images |
66 |
66 |
$2K |
| D4910 |
|
12 |
12 |
$1K |
| D1206 |
Topical application of fluoride varnish |
25 |
25 |
$750.00 |