| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,474 |
2,473 |
$137K |
| D0120 |
Periodic oral evaluation - established patient |
2,302 |
2,301 |
$102K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
633 |
355 |
$68K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,503 |
2,403 |
$56K |
| D0140 |
Limited oral evaluation - problem focused |
1,268 |
1,036 |
$55K |
| D0220 |
Intraoral - periapical first radiographic image |
2,885 |
2,730 |
$43K |
| D0274 |
Bitewings - four radiographic images |
1,252 |
1,250 |
$41K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,637 |
1,636 |
$40K |
| D0210 |
Intraoral - complete series of radiographic images |
518 |
518 |
$38K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
314 |
148 |
$30K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
371 |
371 |
$17K |
| D4341 |
|
40 |
14 |
$9K |
| D1120 |
Prophylaxis - child |
128 |
128 |
$6K |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$975.00 |
| D0170 |
|
17 |
15 |
$315.00 |
| D0350 |
|
49 |
48 |
$245.00 |