| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,218 |
1,218 |
$66K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
466 |
292 |
$39K |
| D0210 |
Intraoral - complete series of radiographic images |
465 |
463 |
$32K |
| D0274 |
Bitewings - four radiographic images |
891 |
891 |
$32K |
| D1120 |
Prophylaxis - child |
452 |
452 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
638 |
638 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
447 |
446 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
558 |
558 |
$8K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
76 |
44 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
50 |
39 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
42 |
12 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
34 |
24 |
$2K |
| D1206 |
Topical application of fluoride varnish |
53 |
53 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
52 |
52 |
$777.74 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$192.10 |