| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,597 |
2,594 |
$106K |
| D0120 |
Periodic oral evaluation - established patient |
2,904 |
2,902 |
$62K |
| D0274 |
Bitewings - four radiographic images |
2,463 |
2,463 |
$52K |
| D0220 |
Intraoral - periapical first radiographic image |
3,117 |
3,093 |
$30K |
| D0210 |
Intraoral - complete series of radiographic images |
420 |
417 |
$16K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,339 |
1,338 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,785 |
2,781 |
$15K |
| D1120 |
Prophylaxis - child |
222 |
221 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
223 |
223 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
82 |
67 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
55 |
48 |
$2K |
| D9110 |
|
28 |
28 |
$437.14 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$132.38 |