| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,716 |
2,710 |
$97K |
| D0120 |
Periodic oral evaluation - established patient |
2,620 |
2,619 |
$52K |
| D0274 |
Bitewings - four radiographic images |
2,438 |
2,437 |
$46K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
663 |
363 |
$31K |
| D0220 |
Intraoral - periapical first radiographic image |
3,069 |
3,059 |
$28K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,839 |
2,831 |
$24K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
337 |
229 |
$19K |
| D4341 |
|
131 |
71 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
230 |
226 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
305 |
304 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
128 |
128 |
$1K |
| D1120 |
Prophylaxis - child |
13 |
13 |
$399.81 |
| D0140 |
Limited oral evaluation - problem focused |
39 |
39 |
$365.79 |