| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
4,188 |
4,139 |
$59K |
| D0120 |
Periodic oral evaluation - established patient |
3,773 |
3,728 |
$48K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,303 |
748 |
$38K |
| D0210 |
Intraoral - complete series of radiographic images |
1,636 |
1,615 |
$38K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,080 |
724 |
$36K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,513 |
1,492 |
$31K |
| D0230 |
Intraoral - periapical each additional radiographic image |
8,217 |
3,703 |
$25K |
| D2750 |
|
98 |
79 |
$22K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
459 |
263 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
4,276 |
4,162 |
$13K |
| D2332 |
|
238 |
124 |
$9K |
| D0272 |
Bitewings - two radiographic images |
2,297 |
2,260 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
368 |
340 |
$5K |
| D0274 |
Bitewings - four radiographic images |
728 |
728 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
117 |
69 |
$3K |
| D2335 |
|
18 |
13 |
$719.50 |
| D2954 |
|
15 |
14 |
$450.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
43 |
43 |
$430.00 |
| D9110 |
|
45 |
42 |
$374.00 |
| D1120 |
Prophylaxis - child |
20 |
20 |
$280.00 |
| D1330 |
|
30 |
30 |
$0.00 |
| D1999 |
|
167 |
152 |
$0.00 |