| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D4210 |
|
734 |
355 |
$234K |
| D1110 |
Prophylaxis - adult |
1,326 |
1,301 |
$84K |
| D0274 |
Bitewings - four radiographic images |
1,641 |
1,613 |
$67K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
594 |
252 |
$63K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
619 |
214 |
$51K |
| D0220 |
Intraoral - periapical first radiographic image |
1,823 |
1,789 |
$33K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
629 |
615 |
$31K |
| D1208 |
Topical application of fluoride, excluding varnish |
971 |
960 |
$29K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,784 |
1,683 |
$26K |
| D0120 |
Periodic oral evaluation - established patient |
802 |
789 |
$22K |
| D0140 |
Limited oral evaluation - problem focused |
245 |
241 |
$11K |
| D0180 |
|
12 |
12 |
$696.00 |
| D1120 |
Prophylaxis - child |
13 |
13 |
$550.00 |