| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,158 |
2,157 |
$82K |
| D0120 |
Periodic oral evaluation - established patient |
2,536 |
2,531 |
$51K |
| D0210 |
Intraoral - complete series of radiographic images |
968 |
967 |
$37K |
| D0274 |
Bitewings - four radiographic images |
696 |
693 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
929 |
926 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
873 |
868 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
31 |
28 |
$1K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
17 |
12 |
$978.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
22 |
12 |
$746.19 |
| D1208 |
Topical application of fluoride, excluding varnish |
47 |
47 |
$495.20 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
14 |
$203.00 |