| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
3,228 |
685 |
$143K |
| D1110 |
Prophylaxis - adult |
2,314 |
2,312 |
$91K |
| D0120 |
Periodic oral evaluation - established patient |
3,288 |
3,285 |
$72K |
| D1120 |
Prophylaxis - child |
1,309 |
1,308 |
$43K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
575 |
260 |
$39K |
| D0330 |
Panoramic radiographic image |
807 |
807 |
$22K |
| D0274 |
Bitewings - four radiographic images |
957 |
956 |
$22K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,549 |
1,548 |
$19K |
| D0272 |
Bitewings - two radiographic images |
1,299 |
1,297 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
287 |
287 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
371 |
369 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
171 |
170 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
15 |
12 |
$783.75 |
| D1206 |
Topical application of fluoride varnish |
41 |
41 |
$725.00 |
| D0140 |
Limited oral evaluation - problem focused |
24 |
24 |
$314.99 |
| D0240 |
|
12 |
12 |
$171.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
43 |
43 |
$165.96 |
| D1999 |
|
45 |
41 |
$0.00 |