| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,125 |
1,115 |
$62K |
| D0120 |
Periodic oral evaluation - established patient |
1,446 |
1,434 |
$35K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
439 |
225 |
$29K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,801 |
972 |
$24K |
| D1208 |
Topical application of fluoride, excluding varnish |
746 |
745 |
$22K |
| D0272 |
Bitewings - two radiographic images |
798 |
793 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
1,086 |
1,072 |
$18K |
| D1120 |
Prophylaxis - child |
191 |
190 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
66 |
66 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$591.00 |