| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
4,015 |
4,010 |
$215K |
| D0120 |
Periodic oral evaluation - established patient |
4,477 |
4,473 |
$121K |
| D0272 |
Bitewings - two radiographic images |
1,043 |
1,043 |
$17K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
83 |
64 |
$8K |
| D1120 |
Prophylaxis - child |
177 |
177 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
80 |
72 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
351 |
351 |
$5K |
| D0274 |
Bitewings - four radiographic images |
132 |
132 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
210 |
209 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
130 |
127 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
58 |
58 |
$2K |
| D2394 |
|
13 |
13 |
$2K |