| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,132 |
999 |
$50K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
115 |
65 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
483 |
425 |
$14K |
| D0210 |
Intraoral - complete series of radiographic images |
229 |
200 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
594 |
527 |
$13K |
| D1206 |
Topical application of fluoride varnish |
449 |
391 |
$8K |
| D0274 |
Bitewings - four radiographic images |
226 |
205 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
364 |
283 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
101 |
86 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
42 |
27 |
$3K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
19 |
13 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
117 |
86 |
$728.42 |