| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,145 |
1,128 |
$40K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
709 |
435 |
$39K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,243 |
1,229 |
$30K |
| D0210 |
Intraoral - complete series of radiographic images |
875 |
861 |
$30K |
| D0120 |
Periodic oral evaluation - established patient |
828 |
813 |
$20K |
| D1120 |
Prophylaxis - child |
560 |
556 |
$20K |
| D0140 |
Limited oral evaluation - problem focused |
362 |
337 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
244 |
139 |
$10K |
| D2750 |
|
19 |
15 |
$6K |
| D0274 |
Bitewings - four radiographic images |
601 |
589 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
223 |
222 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
129 |
66 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
916 |
902 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
724 |
704 |
$3K |
| D9920 |
|
74 |
74 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
23 |
17 |
$998.00 |
| D0272 |
Bitewings - two radiographic images |
100 |
99 |
$780.00 |
| D0603 |
|
25 |
25 |
$250.00 |
| D0601 |
|
14 |
14 |
$110.00 |
| D1330 |
|
946 |
896 |
$0.00 |