| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,840 |
1,839 |
$97K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
812 |
565 |
$58K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
583 |
443 |
$57K |
| D0274 |
Bitewings - four radiographic images |
1,253 |
1,253 |
$33K |
| D0120 |
Periodic oral evaluation - established patient |
1,246 |
1,246 |
$33K |
| D0220 |
Intraoral - periapical first radiographic image |
1,909 |
1,877 |
$24K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
513 |
513 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,490 |
1,485 |
$14K |
| D0210 |
Intraoral - complete series of radiographic images |
368 |
363 |
$14K |
| D2750 |
|
14 |
12 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
33 |
26 |
$4K |
| D4342 |
|
67 |
46 |
$4K |
| D2954 |
|
17 |
14 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
181 |
180 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
135 |
135 |
$2K |
| D1120 |
Prophylaxis - child |
24 |
24 |
$903.00 |
| D1999 |
|
26 |
25 |
$0.00 |