| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,656 |
3,653 |
$171K |
| D0120 |
Periodic oral evaluation - established patient |
3,178 |
3,177 |
$79K |
| D0210 |
Intraoral - complete series of radiographic images |
1,535 |
1,529 |
$71K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
594 |
386 |
$43K |
| D0274 |
Bitewings - four radiographic images |
1,610 |
1,610 |
$40K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,432 |
1,432 |
$37K |
| D0220 |
Intraoral - periapical first radiographic image |
1,760 |
1,740 |
$22K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,228 |
1,228 |
$16K |
| D1120 |
Prophylaxis - child |
353 |
353 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
245 |
134 |
$11K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
133 |
79 |
$11K |
| D9110 |
|
418 |
414 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
336 |
325 |
$4K |
| D2140 |
|
14 |
12 |
$980.50 |
| D0140 |
Limited oral evaluation - problem focused |
74 |
74 |
$909.78 |
| D1999 |
|
58 |
51 |
$0.00 |