| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,682 |
1,670 |
$70K |
| D0120 |
Periodic oral evaluation - established patient |
1,485 |
1,478 |
$34K |
| D0220 |
Intraoral - periapical first radiographic image |
2,395 |
2,257 |
$29K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
243 |
149 |
$29K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,439 |
1,522 |
$27K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
330 |
143 |
$27K |
| D0274 |
Bitewings - four radiographic images |
806 |
801 |
$21K |
| D0140 |
Limited oral evaluation - problem focused |
342 |
336 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
54 |
32 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
224 |
222 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
24 |
24 |
$622.50 |