| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,250 |
1,207 |
$39K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
612 |
280 |
$29K |
| D0120 |
Periodic oral evaluation - established patient |
1,286 |
1,259 |
$26K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,849 |
1,781 |
$23K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
917 |
841 |
$22K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
374 |
125 |
$14K |
| D0210 |
Intraoral - complete series of radiographic images |
473 |
439 |
$11K |
| D0274 |
Bitewings - four radiographic images |
1,146 |
1,112 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
528 |
505 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
1,300 |
1,236 |
$8K |
| D1120 |
Prophylaxis - child |
403 |
384 |
$8K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
82 |
50 |
$5K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
43 |
27 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,194 |
656 |
$2K |
| D2332 |
|
18 |
12 |
$1K |