| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,103 |
1,101 |
$22K |
| D0120 |
Periodic oral evaluation - established patient |
1,323 |
1,322 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
1,320 |
1,293 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
393 |
391 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
243 |
119 |
$3K |
| D0274 |
Bitewings - four radiographic images |
463 |
463 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,035 |
1,035 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
133 |
93 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
123 |
123 |
$1K |
| D1120 |
Prophylaxis - child |
237 |
237 |
$905.60 |
| D0140 |
Limited oral evaluation - problem focused |
53 |
53 |
$546.60 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
30 |
16 |
$381.60 |
| D0210 |
Intraoral - complete series of radiographic images |
55 |
55 |
$332.75 |
| D0272 |
Bitewings - two radiographic images |
111 |
111 |
$65.50 |