| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,174 |
1,020 |
$35K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,135 |
1,020 |
$26K |
| D0274 |
Bitewings - four radiographic images |
805 |
716 |
$13K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
192 |
89 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
1,439 |
1,269 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
595 |
514 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
414 |
371 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
923 |
610 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
196 |
156 |
$3K |
| D1120 |
Prophylaxis - child |
99 |
93 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
20 |
12 |
$1K |
| D2940 |
|
33 |
25 |
$986.36 |