| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,942 |
1,935 |
$64K |
| D0120 |
Periodic oral evaluation - established patient |
1,023 |
1,020 |
$20K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
349 |
276 |
$20K |
| D0210 |
Intraoral - complete series of radiographic images |
436 |
432 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
599 |
596 |
$14K |
| D0140 |
Limited oral evaluation - problem focused |
615 |
601 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
357 |
253 |
$13K |
| D0274 |
Bitewings - four radiographic images |
535 |
535 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
1,078 |
1,055 |
$8K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
98 |
80 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
157 |
55 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
122 |
74 |
$533.15 |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$60.00 |
| D1206 |
Topical application of fluoride varnish |
13 |
12 |
$50.00 |
| D9995 |
|
14 |
14 |
$0.00 |