| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,055 |
1,055 |
$47K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
632 |
421 |
$44K |
| D0120 |
Periodic oral evaluation - established patient |
1,454 |
1,454 |
$36K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
315 |
224 |
$17K |
| D0274 |
Bitewings - four radiographic images |
1,300 |
1,300 |
$16K |
| D1120 |
Prophylaxis - child |
319 |
319 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
527 |
526 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
1,805 |
1,787 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,585 |
1,584 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
117 |
115 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
53 |
44 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
109 |
109 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
16 |
12 |
$800.00 |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$540.00 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$480.00 |