| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,150 |
2,105 |
$92K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
442 |
224 |
$59K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,506 |
1,486 |
$58K |
| D0220 |
Intraoral - periapical first radiographic image |
4,377 |
4,261 |
$54K |
| D0120 |
Periodic oral evaluation - established patient |
2,084 |
2,053 |
$47K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,340 |
2,296 |
$35K |
| D0140 |
Limited oral evaluation - problem focused |
871 |
856 |
$30K |
| D0210 |
Intraoral - complete series of radiographic images |
349 |
347 |
$28K |
| D0274 |
Bitewings - four radiographic images |
926 |
909 |
$27K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
103 |
62 |
$16K |
| D7140 |
Extraction, erupted tooth or exposed root |
34 |
24 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
55 |
55 |
$642.40 |