| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,113 |
2,113 |
$105K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
520 |
298 |
$46K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,164 |
1,164 |
$45K |
| D0120 |
Periodic oral evaluation - established patient |
1,758 |
1,758 |
$40K |
| D1206 |
Topical application of fluoride varnish |
1,932 |
1,932 |
$32K |
| D0274 |
Bitewings - four radiographic images |
1,098 |
1,098 |
$29K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
265 |
185 |
$28K |
| D0220 |
Intraoral - periapical first radiographic image |
1,577 |
1,559 |
$19K |
| D0210 |
Intraoral - complete series of radiographic images |
381 |
381 |
$19K |
| D0140 |
Limited oral evaluation - problem focused |
465 |
465 |
$17K |
| D1120 |
Prophylaxis - child |
360 |
360 |
$12K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
61 |
40 |
$8K |
| D0330 |
Panoramic radiographic image |
197 |
197 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
550 |
505 |
$5K |
| D0272 |
Bitewings - two radiographic images |
83 |
83 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
17 |
14 |
$1K |
| D0240 |
|
23 |
13 |
$359.75 |