| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
5,253 |
5,252 |
$176K |
| D0120 |
Periodic oral evaluation - established patient |
4,828 |
4,827 |
$86K |
| D0220 |
Intraoral - periapical first radiographic image |
5,738 |
5,724 |
$58K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,706 |
4,677 |
$54K |
| D0210 |
Intraoral - complete series of radiographic images |
3,422 |
3,385 |
$50K |
| D0274 |
Bitewings - four radiographic images |
1,769 |
1,768 |
$28K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
526 |
526 |
$11K |
| D4341 |
|
231 |
62 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
668 |
668 |
$7K |
| D1206 |
Topical application of fluoride varnish |
61 |
61 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
50 |
26 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
26 |
18 |
$1K |
| D9110 |
|
14 |
14 |
$240.15 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$103.27 |