| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
4,321 |
4,306 |
$182K |
| D0120 |
Periodic oral evaluation - established patient |
4,093 |
4,079 |
$92K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,243 |
1,031 |
$92K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,190 |
972 |
$75K |
| D0274 |
Bitewings - four radiographic images |
2,751 |
2,750 |
$58K |
| D0210 |
Intraoral - complete series of radiographic images |
1,075 |
1,072 |
$37K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,580 |
3,566 |
$36K |
| D0220 |
Intraoral - periapical first radiographic image |
3,985 |
3,954 |
$35K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,060 |
1,060 |
$28K |
| D1120 |
Prophylaxis - child |
692 |
690 |
$26K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
139 |
108 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
778 |
775 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
816 |
802 |
$10K |
| D7140 |
Extraction, erupted tooth or exposed root |
24 |
13 |
$1K |
| D2330 |
|
16 |
12 |
$915.06 |