| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
981 |
977 |
$53K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
269 |
166 |
$37K |
| D0210 |
Intraoral - complete series of radiographic images |
399 |
395 |
$33K |
| D0120 |
Periodic oral evaluation - established patient |
1,005 |
1,002 |
$27K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
367 |
364 |
$17K |
| D0274 |
Bitewings - four radiographic images |
501 |
501 |
$16K |
| D1206 |
Topical application of fluoride varnish |
450 |
450 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
52 |
37 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
430 |
418 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
51 |
26 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
114 |
113 |
$4K |
| D1120 |
Prophylaxis - child |
88 |
88 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
17 |
13 |
$2K |
| D4910 |
|
12 |
12 |
$807.36 |