| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,593 |
3,555 |
$64K |
| D0120 |
Periodic oral evaluation - established patient |
3,191 |
3,152 |
$59K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,457 |
3,337 |
$25K |
| D2750 |
|
74 |
54 |
$16K |
| D0274 |
Bitewings - four radiographic images |
2,187 |
2,154 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
3,729 |
3,616 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
366 |
254 |
$14K |
| D0210 |
Intraoral - complete series of radiographic images |
510 |
502 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
570 |
565 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
256 |
173 |
$8K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
152 |
104 |
$7K |
| D1120 |
Prophylaxis - child |
228 |
226 |
$3K |
| D2954 |
|
40 |
27 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
80 |
79 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
124 |
122 |
$1K |
| D9110 |
|
41 |
40 |
$360.00 |
| D0272 |
Bitewings - two radiographic images |
56 |
55 |
$260.00 |
| D0270 |
|
13 |
13 |
$39.00 |