| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,810 |
2,807 |
$106K |
| D0120 |
Periodic oral evaluation - established patient |
3,300 |
3,291 |
$69K |
| D0274 |
Bitewings - four radiographic images |
2,386 |
2,385 |
$48K |
| D1120 |
Prophylaxis - child |
1,307 |
1,301 |
$40K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
481 |
379 |
$32K |
| D2750 |
|
29 |
20 |
$29K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,893 |
1,889 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
892 |
892 |
$18K |
| D9990 |
|
734 |
580 |
$16K |
| D0140 |
Limited oral evaluation - problem focused |
1,148 |
1,124 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
118 |
84 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
495 |
487 |
$4K |
| D2954 |
|
17 |
14 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
642 |
617 |
$3K |
| D9110 |
|
102 |
101 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
25 |
25 |
$876.60 |