| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,540 |
2,540 |
$84K |
| D0120 |
Periodic oral evaluation - established patient |
3,706 |
3,705 |
$66K |
| D0274 |
Bitewings - four radiographic images |
3,495 |
3,494 |
$62K |
| D0220 |
Intraoral - periapical first radiographic image |
4,276 |
4,206 |
$34K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
614 |
438 |
$33K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,678 |
3,671 |
$16K |
| D1120 |
Prophylaxis - child |
548 |
548 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,177 |
1,176 |
$12K |
| D2954 |
|
115 |
107 |
$11K |
| D0140 |
Limited oral evaluation - problem focused |
768 |
744 |
$9K |
| D2791 |
|
31 |
30 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
81 |
58 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
44 |
44 |
$1K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
15 |
12 |
$872.90 |