| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,482 |
1,457 |
$54K |
| D0120 |
Periodic oral evaluation - established patient |
2,097 |
2,067 |
$49K |
| D1120 |
Prophylaxis - child |
547 |
543 |
$20K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
379 |
197 |
$16K |
| D0274 |
Bitewings - four radiographic images |
1,258 |
1,243 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
218 |
142 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
439 |
439 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
287 |
287 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
117 |
117 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
110 |
109 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
266 |
264 |
$968.25 |
| D0230 |
Intraoral - periapical each additional radiographic image |
168 |
167 |
$642.75 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$72.00 |