| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,773 |
1,772 |
$58K |
| D0120 |
Periodic oral evaluation - established patient |
1,814 |
1,813 |
$35K |
| D0274 |
Bitewings - four radiographic images |
1,330 |
1,330 |
$24K |
| D0210 |
Intraoral - complete series of radiographic images |
496 |
495 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
1,582 |
1,573 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
186 |
154 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,414 |
1,412 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
49 |
45 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
152 |
152 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
41 |
41 |
$875.04 |
| D4341 |
|
13 |
13 |
$756.84 |