| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,102 |
1,087 |
$35K |
| D0120 |
Periodic oral evaluation - established patient |
1,300 |
1,283 |
$32K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
503 |
338 |
$29K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,080 |
1,064 |
$16K |
| D0274 |
Bitewings - four radiographic images |
692 |
684 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,209 |
823 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
939 |
919 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
101 |
83 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
198 |
195 |
$6K |
| D1110 |
Prophylaxis - adult |
126 |
125 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
35 |
31 |
$3K |
| D2394 |
|
35 |
29 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
49 |
47 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
30 |
29 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
19 |
13 |
$848.00 |
| D0330 |
Panoramic radiographic image |
15 |
15 |
$258.00 |