| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,434 |
2,434 |
$132K |
| D0120 |
Periodic oral evaluation - established patient |
2,934 |
2,933 |
$78K |
| D0274 |
Bitewings - four radiographic images |
2,677 |
2,677 |
$74K |
| D0220 |
Intraoral - periapical first radiographic image |
3,938 |
3,921 |
$52K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,470 |
3,467 |
$37K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
296 |
277 |
$34K |
| D1120 |
Prophylaxis - child |
747 |
747 |
$30K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
559 |
559 |
$16K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
110 |
104 |
$15K |
| D0140 |
Limited oral evaluation - problem focused |
818 |
803 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
138 |
130 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
571 |
571 |
$8K |
| D0272 |
Bitewings - two radiographic images |
301 |
301 |
$5K |
| D2332 |
|
28 |
24 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
425 |
423 |
$2K |
| D0270 |
|
76 |
74 |
$960.68 |