| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,006 |
3,002 |
$107K |
| D0120 |
Periodic oral evaluation - established patient |
2,632 |
2,628 |
$49K |
| D0274 |
Bitewings - four radiographic images |
2,254 |
2,252 |
$39K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,609 |
2,592 |
$24K |
| D0220 |
Intraoral - periapical first radiographic image |
2,404 |
2,369 |
$13K |
| D0210 |
Intraoral - complete series of radiographic images |
155 |
155 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
378 |
374 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
46 |
25 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
113 |
113 |
$2K |
| D2394 |
|
28 |
24 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
17 |
12 |
$787.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
41 |
41 |
$410.00 |