| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
780 |
778 |
$35K |
| D4341 |
|
351 |
137 |
$31K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
731 |
730 |
$27K |
| D0210 |
Intraoral - complete series of radiographic images |
441 |
440 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
840 |
838 |
$23K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,112 |
1,110 |
$21K |
| D0140 |
Limited oral evaluation - problem focused |
486 |
481 |
$17K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
208 |
91 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,370 |
494 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
907 |
893 |
$11K |
| D0274 |
Bitewings - four radiographic images |
376 |
376 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
116 |
55 |
$6K |
| D4910 |
|
45 |
45 |
$3K |
| D0602 |
|
219 |
219 |
$2K |
| D0603 |
|
218 |
218 |
$2K |
| D0270 |
|
126 |
126 |
$1K |
| D0601 |
|
78 |
78 |
$803.20 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$480.00 |