| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
710 |
589 |
$20K |
| D1208 |
Topical application of fluoride, excluding varnish |
900 |
786 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
746 |
646 |
$14K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
172 |
72 |
$14K |
| D0274 |
Bitewings - four radiographic images |
479 |
400 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
433 |
352 |
$11K |
| D0140 |
Limited oral evaluation - problem focused |
478 |
356 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
167 |
134 |
$7K |
| D2394 |
|
123 |
37 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
213 |
76 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
745 |
581 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
396 |
167 |
$3K |
| D2332 |
|
28 |
12 |
$3K |
| D1120 |
Prophylaxis - child |
57 |
55 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
48 |
25 |
$2K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
81 |
29 |
$2K |
| D0330 |
Panoramic radiographic image |
18 |
14 |
$555.93 |
| D1206 |
Topical application of fluoride varnish |
33 |
31 |
$447.18 |