| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,683 |
1,683 |
$67K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
627 |
361 |
$63K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
717 |
315 |
$58K |
| D0210 |
Intraoral - complete series of radiographic images |
963 |
963 |
$56K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,045 |
1,045 |
$37K |
| D1206 |
Topical application of fluoride varnish |
1,142 |
1,142 |
$26K |
| D0120 |
Periodic oral evaluation - established patient |
784 |
784 |
$22K |
| D0140 |
Limited oral evaluation - problem focused |
357 |
354 |
$11K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
42 |
32 |
$6K |
| D4341 |
|
76 |
40 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
387 |
384 |
$4K |
| D0274 |
Bitewings - four radiographic images |
120 |
120 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
16 |
13 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
16 |
13 |
$122.64 |