| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,682 |
2,659 |
$137K |
| D0120 |
Periodic oral evaluation - established patient |
2,746 |
2,719 |
$75K |
| D0274 |
Bitewings - four radiographic images |
1,342 |
1,335 |
$45K |
| D0140 |
Limited oral evaluation - problem focused |
450 |
440 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
831 |
818 |
$10K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
235 |
184 |
$5K |
| D1206 |
Topical application of fluoride varnish |
219 |
218 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
729 |
308 |
$3K |
| D1120 |
Prophylaxis - child |
140 |
140 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
289 |
289 |
$2K |
| D0272 |
Bitewings - two radiographic images |
57 |
57 |
$1K |
| D2140 |
|
103 |
75 |
$1K |
| D2331 |
|
148 |
80 |
$798.24 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
109 |
78 |
$105.94 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
124 |
92 |
$84.71 |
| D7140 |
Extraction, erupted tooth or exposed root |
88 |
48 |
$0.00 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
14 |
14 |
$0.00 |
| D2330 |
|
47 |
30 |
$0.00 |
| D2332 |
|
17 |
13 |
$0.00 |