| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,563 |
1,334 |
$64K |
| D0120 |
Periodic oral evaluation - established patient |
1,993 |
1,707 |
$39K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
351 |
204 |
$23K |
| D0274 |
Bitewings - four radiographic images |
646 |
562 |
$21K |
| D1120 |
Prophylaxis - child |
172 |
150 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
80 |
72 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
44 |
24 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
77 |
63 |
$2K |
| D1206 |
Topical application of fluoride varnish |
134 |
114 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
15 |
14 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
88 |
68 |
$982.15 |
| D1208 |
Topical application of fluoride, excluding varnish |
24 |
13 |
$291.15 |