| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,914 |
2,913 |
$119K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
787 |
600 |
$54K |
| D0120 |
Periodic oral evaluation - established patient |
2,346 |
2,343 |
$48K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
593 |
452 |
$28K |
| D0274 |
Bitewings - four radiographic images |
1,329 |
1,329 |
$27K |
| D0220 |
Intraoral - periapical first radiographic image |
2,432 |
2,408 |
$24K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,818 |
1,815 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
825 |
825 |
$14K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
66 |
62 |
$6K |
| D2750 |
|
16 |
12 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
541 |
533 |
$5K |
| D0350 |
|
406 |
406 |
$4K |
| D1120 |
Prophylaxis - child |
90 |
90 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
303 |
300 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
225 |
225 |
$2K |