| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,271 |
1,269 |
$76K |
| D0120 |
Periodic oral evaluation - established patient |
1,942 |
1,942 |
$60K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
447 |
270 |
$40K |
| D0210 |
Intraoral - complete series of radiographic images |
422 |
422 |
$32K |
| D0274 |
Bitewings - four radiographic images |
838 |
836 |
$30K |
| D1120 |
Prophylaxis - child |
562 |
562 |
$27K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
527 |
527 |
$16K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
264 |
185 |
$16K |
| D1208 |
Topical application of fluoride, excluding varnish |
951 |
951 |
$15K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
84 |
72 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
646 |
618 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
138 |
54 |
$9K |
| D4910 |
|
106 |
106 |
$5K |
| D0330 |
Panoramic radiographic image |
72 |
72 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
84 |
81 |
$2K |
| D4341 |
|
31 |
14 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
101 |
98 |
$866.61 |
| D1206 |
Topical application of fluoride varnish |
43 |
43 |
$528.50 |