| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,431 |
1,372 |
$55K |
| D0120 |
Periodic oral evaluation - established patient |
1,554 |
1,506 |
$27K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
351 |
125 |
$20K |
| D0274 |
Bitewings - four radiographic images |
731 |
695 |
$16K |
| D1208 |
Topical application of fluoride, excluding varnish |
768 |
759 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
1,658 |
1,392 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,689 |
1,138 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
104 |
50 |
$10K |
| D9630 |
|
383 |
382 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
124 |
115 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
237 |
206 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
85 |
80 |
$2K |
| D1120 |
Prophylaxis - child |
27 |
27 |
$905.04 |
| D9994 |
|
69 |
69 |
$0.00 |