| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,507 |
1,458 |
$48K |
| D2394 |
|
360 |
216 |
$27K |
| D0120 |
Periodic oral evaluation - established patient |
1,613 |
1,561 |
$27K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
389 |
241 |
$25K |
| D0274 |
Bitewings - four radiographic images |
1,307 |
1,266 |
$25K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
317 |
170 |
$17K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,602 |
1,269 |
$13K |
| D0210 |
Intraoral - complete series of radiographic images |
213 |
193 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
1,779 |
1,589 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
406 |
350 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
543 |
514 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
143 |
136 |
$4K |
| D1120 |
Prophylaxis - child |
155 |
145 |
$3K |
| D2160 |
|
20 |
12 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
23 |
12 |
$1K |