| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,166 |
2,162 |
$100K |
| D0120 |
Periodic oral evaluation - established patient |
3,553 |
3,533 |
$56K |
| D1120 |
Prophylaxis - child |
1,791 |
1,775 |
$51K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
258 |
191 |
$19K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,795 |
1,780 |
$14K |
| D0274 |
Bitewings - four radiographic images |
576 |
576 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
415 |
405 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
104 |
103 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
63 |
44 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
137 |
137 |
$3K |
| D0272 |
Bitewings - two radiographic images |
246 |
245 |
$3K |
| D0601 |
|
337 |
331 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
39 |
39 |
$327.60 |
| D0602 |
|
26 |
26 |
$250.00 |