| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
620 |
618 |
$52K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
714 |
714 |
$44K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
534 |
266 |
$28K |
| D0210 |
Intraoral - complete series of radiographic images |
554 |
554 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
491 |
487 |
$20K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
257 |
170 |
$17K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,583 |
609 |
$15K |
| D1208 |
Topical application of fluoride, excluding varnish |
531 |
529 |
$6K |
| D1206 |
Topical application of fluoride varnish |
315 |
315 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
91 |
46 |
$5K |
| D0272 |
Bitewings - two radiographic images |
346 |
344 |
$4K |
| D4341 |
|
34 |
13 |
$2K |
| D2954 |
|
20 |
12 |
$2K |
| D1120 |
Prophylaxis - child |
69 |
69 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
49 |
49 |
$588.00 |