| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,810 |
1,805 |
$78K |
| D0120 |
Periodic oral evaluation - established patient |
2,164 |
2,152 |
$53K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
710 |
413 |
$49K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
560 |
333 |
$31K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,239 |
1,218 |
$30K |
| D1120 |
Prophylaxis - child |
520 |
519 |
$23K |
| D0274 |
Bitewings - four radiographic images |
1,902 |
1,890 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
381 |
380 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
188 |
187 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
171 |
171 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
724 |
711 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
38 |
25 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
591 |
574 |
$2K |
| D2954 |
|
13 |
12 |
$1K |
| D1206 |
Topical application of fluoride varnish |
82 |
76 |
$1K |
| D0272 |
Bitewings - two radiographic images |
46 |
46 |
$460.00 |
| D4355 |
|
23 |
16 |
$115.00 |