| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,878 |
1,875 |
$65K |
| D0120 |
Periodic oral evaluation - established patient |
1,681 |
1,678 |
$34K |
| D0210 |
Intraoral - complete series of radiographic images |
1,091 |
1,084 |
$32K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
404 |
291 |
$24K |
| D0220 |
Intraoral - periapical first radiographic image |
1,836 |
1,803 |
$17K |
| D0274 |
Bitewings - four radiographic images |
900 |
900 |
$17K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,614 |
1,609 |
$13K |
| D2750 |
|
32 |
30 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
268 |
268 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
28 |
26 |
$1K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
17 |
15 |
$1K |
| D1120 |
Prophylaxis - child |
25 |
25 |
$770.16 |
| D1208 |
Topical application of fluoride, excluding varnish |
38 |
38 |
$392.30 |
| D9110 |
|
15 |
13 |
$237.82 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$129.91 |