| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
778 |
775 |
$49K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
224 |
138 |
$30K |
| D0120 |
Periodic oral evaluation - established patient |
870 |
863 |
$26K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
426 |
424 |
$24K |
| D3120 |
|
626 |
265 |
$22K |
| D1206 |
Topical application of fluoride varnish |
632 |
625 |
$16K |
| D1208 |
Topical application of fluoride, excluding varnish |
593 |
593 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
1,261 |
1,229 |
$13K |
| D0274 |
Bitewings - four radiographic images |
480 |
470 |
$11K |
| D0210 |
Intraoral - complete series of radiographic images |
187 |
187 |
$11K |
| D1120 |
Prophylaxis - child |
146 |
146 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
764 |
752 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
80 |
77 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
21 |
13 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
21 |
12 |
$2K |
| D2950 |
|
18 |
13 |
$2K |
| D0330 |
Panoramic radiographic image |
33 |
33 |
$2K |
| D1330 |
|
126 |
122 |
$732.00 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$180.00 |