| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,164 |
2,154 |
$99K |
| D0120 |
Periodic oral evaluation - established patient |
2,961 |
2,952 |
$78K |
| D1120 |
Prophylaxis - child |
657 |
655 |
$31K |
| D1206 |
Topical application of fluoride varnish |
923 |
922 |
$30K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
342 |
232 |
$17K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
189 |
128 |
$12K |
| D2750 |
|
18 |
14 |
$10K |
| D0274 |
Bitewings - four radiographic images |
700 |
699 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
150 |
150 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
38 |
38 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
27 |
26 |
$1K |
| D2394 |
|
13 |
12 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
57 |
56 |
$299.25 |