| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,714 |
2,710 |
$145K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,223 |
872 |
$99K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,310 |
820 |
$75K |
| D0120 |
Periodic oral evaluation - established patient |
2,681 |
2,676 |
$74K |
| D0210 |
Intraoral - complete series of radiographic images |
507 |
507 |
$27K |
| D0274 |
Bitewings - four radiographic images |
982 |
981 |
$27K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
81 |
64 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
142 |
142 |
$4K |
| D2330 |
|
45 |
28 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
151 |
151 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
21 |
16 |
$1K |
| D1120 |
Prophylaxis - child |
13 |
12 |
$500.95 |
| D0140 |
Limited oral evaluation - problem focused |
17 |
17 |
$233.10 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$149.82 |
| D1999 |
|
27 |
21 |
$0.00 |