| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,397 |
2,393 |
$97K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
513 |
294 |
$70K |
| D0120 |
Periodic oral evaluation - established patient |
1,903 |
1,903 |
$42K |
| D0274 |
Bitewings - four radiographic images |
1,190 |
1,190 |
$34K |
| D0160 |
|
444 |
442 |
$31K |
| D0220 |
Intraoral - periapical first radiographic image |
2,003 |
1,966 |
$24K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,578 |
1,566 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
568 |
563 |
$21K |
| D0210 |
Intraoral - complete series of radiographic images |
255 |
249 |
$18K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
163 |
100 |
$17K |
| D0140 |
Limited oral evaluation - problem focused |
496 |
488 |
$16K |
| D9110 |
|
49 |
46 |
$3K |
| D0460 |
|
81 |
80 |
$2K |
| D1206 |
Topical application of fluoride varnish |
49 |
49 |
$799.61 |
| D1120 |
Prophylaxis - child |
14 |
14 |
$416.23 |