| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,260 |
1,247 |
$106K |
| D0120 |
Periodic oral evaluation - established patient |
1,506 |
1,493 |
$84K |
| D0230 |
Intraoral - periapical each additional radiographic image |
12,572 |
2,760 |
$52K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
523 |
521 |
$31K |
| D0274 |
Bitewings - four radiographic images |
1,352 |
1,338 |
$28K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,974 |
1,956 |
$26K |
| D4341 |
|
277 |
81 |
$19K |
| D1120 |
Prophylaxis - child |
267 |
266 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
96 |
61 |
$6K |
| D9430 |
|
80 |
69 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
34 |
24 |
$2K |
| D1320 |
|
88 |
88 |
$1K |
| D9110 |
|
18 |
15 |
$1K |
| D0272 |
Bitewings - two radiographic images |
30 |
30 |
$312.00 |
| D1999 |
|
308 |
283 |
$161.00 |
| D0270 |
|
28 |
27 |
$135.00 |
| D1330 |
|
977 |
968 |
$0.00 |