| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,864 |
3,864 |
$113K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,555 |
1,313 |
$69K |
| D0120 |
Periodic oral evaluation - established patient |
4,380 |
4,380 |
$65K |
| D0274 |
Bitewings - four radiographic images |
4,105 |
4,105 |
$57K |
| D0220 |
Intraoral - periapical first radiographic image |
4,836 |
4,798 |
$24K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
627 |
544 |
$21K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,435 |
4,424 |
$18K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,664 |
1,664 |
$16K |
| D1120 |
Prophylaxis - child |
450 |
450 |
$11K |
| D0140 |
Limited oral evaluation - problem focused |
514 |
507 |
$8K |
| D0270 |
|
292 |
291 |
$1K |
| D0272 |
Bitewings - two radiographic images |
25 |
25 |
$188.04 |