| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,015 |
1,013 |
$47K |
| D0120 |
Periodic oral evaluation - established patient |
863 |
862 |
$24K |
| D0274 |
Bitewings - four radiographic images |
490 |
490 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
859 |
845 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
289 |
288 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
190 |
114 |
$11K |
| D0140 |
Limited oral evaluation - problem focused |
264 |
261 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
766 |
518 |
$6K |
| D0602 |
|
583 |
582 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
81 |
81 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
55 |
41 |
$4K |
| D4341 |
|
38 |
15 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
108 |
107 |
$2K |
| D1120 |
Prophylaxis - child |
12 |
12 |
$480.00 |
| D0601 |
|
34 |
34 |
$300.00 |
| D0270 |
|
16 |
16 |
$176.00 |
| D1330 |
|
225 |
224 |
$30.00 |