| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
4,150 |
4,149 |
$168K |
| D0120 |
Periodic oral evaluation - established patient |
3,209 |
3,208 |
$69K |
| D0220 |
Intraoral - periapical first radiographic image |
4,899 |
4,889 |
$51K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,356 |
4,352 |
$50K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,169 |
2,169 |
$49K |
| D0272 |
Bitewings - two radiographic images |
3,332 |
3,331 |
$41K |
| D0210 |
Intraoral - complete series of radiographic images |
1,596 |
1,595 |
$29K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
742 |
473 |
$29K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
504 |
368 |
$28K |
| D1120 |
Prophylaxis - child |
343 |
343 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
252 |
252 |
$3K |
| D4341 |
|
56 |
24 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
15 |
13 |
$936.04 |
| D0140 |
Limited oral evaluation - problem focused |
29 |
29 |
$293.01 |