| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,768 |
2,615 |
$101K |
| D0140 |
Limited oral evaluation - problem focused |
2,519 |
2,174 |
$82K |
| D0274 |
Bitewings - four radiographic images |
2,550 |
2,407 |
$75K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,793 |
1,693 |
$74K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,847 |
2,532 |
$70K |
| D0220 |
Intraoral - periapical first radiographic image |
3,580 |
3,218 |
$49K |
| D0120 |
Periodic oral evaluation - established patient |
1,813 |
1,731 |
$44K |
| D1208 |
Topical application of fluoride, excluding varnish |
414 |
407 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
22 |
13 |
$2K |
| D4355 |
|
12 |
12 |
$884.64 |
| D1120 |
Prophylaxis - child |
17 |
16 |
$413.92 |
| D1203 |
|
14 |
12 |
$0.00 |