| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
4,657 |
4,604 |
$65K |
| D0120 |
Periodic oral evaluation - established patient |
4,206 |
4,156 |
$65K |
| D0210 |
Intraoral - complete series of radiographic images |
2,257 |
2,246 |
$45K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,130 |
667 |
$43K |
| D2750 |
|
113 |
78 |
$32K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,601 |
3,550 |
$26K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,314 |
2,301 |
$25K |
| D0274 |
Bitewings - four radiographic images |
2,572 |
2,526 |
$22K |
| D4355 |
|
268 |
268 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
4,988 |
4,851 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,330 |
4,235 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
295 |
173 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
359 |
357 |
$6K |
| D1120 |
Prophylaxis - child |
231 |
229 |
$5K |
| D0170 |
|
396 |
372 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
60 |
40 |
$3K |
| D1206 |
Topical application of fluoride varnish |
206 |
201 |
$3K |
| D0273 |
|
43 |
43 |
$490.00 |
| D0601 |
|
83 |
80 |
$490.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
31 |
12 |
$400.00 |
| D0330 |
Panoramic radiographic image |
27 |
27 |
$90.00 |
| D0270 |
|
30 |
30 |
$4.80 |