| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,948 |
3,945 |
$180K |
| D0120 |
Periodic oral evaluation - established patient |
4,246 |
4,242 |
$97K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,519 |
1,059 |
$87K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,588 |
4,572 |
$68K |
| D0220 |
Intraoral - periapical first radiographic image |
5,074 |
5,046 |
$55K |
| D0274 |
Bitewings - four radiographic images |
2,047 |
2,047 |
$42K |
| D0210 |
Intraoral - complete series of radiographic images |
2,331 |
2,304 |
$40K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
346 |
302 |
$25K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,093 |
1,091 |
$12K |
| D1120 |
Prophylaxis - child |
163 |
162 |
$5K |
| D4341 |
|
42 |
25 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
124 |
124 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
236 |
232 |
$3K |