| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
5,069 |
5,057 |
$46K |
| D1110 |
Prophylaxis - adult |
4,283 |
4,269 |
$45K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,117 |
644 |
$21K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
834 |
562 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,026 |
1,023 |
$10K |
| D1120 |
Prophylaxis - child |
948 |
947 |
$10K |
| D0274 |
Bitewings - four radiographic images |
1,933 |
1,930 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
3,971 |
3,918 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
535 |
533 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
582 |
571 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,419 |
3,394 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,363 |
1,361 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
141 |
86 |
$4K |
| D2330 |
|
127 |
69 |
$2K |
| D2335 |
|
19 |
13 |
$1K |
| D0272 |
Bitewings - two radiographic images |
277 |
277 |
$847.75 |
| D7140 |
Extraction, erupted tooth or exposed root |
22 |
12 |
$120.00 |
| D0603 |
|
15 |
15 |
$80.00 |
| D1206 |
Topical application of fluoride varnish |
14 |
13 |
$0.00 |