| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
539 |
527 |
$19K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
204 |
95 |
$16K |
| D0210 |
Intraoral - complete series of radiographic images |
305 |
297 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
473 |
458 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
82 |
38 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
349 |
340 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
202 |
185 |
$5K |
| D1120 |
Prophylaxis - child |
133 |
132 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
75 |
28 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
396 |
365 |
$4K |
| D0274 |
Bitewings - four radiographic images |
107 |
106 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
79 |
79 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
275 |
250 |
$2K |
| D4355 |
|
17 |
13 |
$926.45 |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
15 |
12 |
$876.35 |
| D1206 |
Topical application of fluoride varnish |
25 |
25 |
$479.29 |