| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,273 |
2,273 |
$82K |
| D0220 |
Intraoral - periapical first radiographic image |
2,876 |
2,871 |
$27K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
475 |
354 |
$26K |
| D0120 |
Periodic oral evaluation - established patient |
1,166 |
1,166 |
$24K |
| D0274 |
Bitewings - four radiographic images |
1,218 |
1,218 |
$23K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,563 |
2,562 |
$23K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,051 |
1,051 |
$22K |
| D0210 |
Intraoral - complete series of radiographic images |
1,392 |
1,391 |
$17K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
367 |
252 |
$13K |
| D4341 |
|
34 |
13 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
81 |
80 |
$788.84 |
| D1120 |
Prophylaxis - child |
14 |
14 |
$429.24 |