| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,835 |
1,833 |
$79K |
| D0120 |
Periodic oral evaluation - established patient |
1,829 |
1,827 |
$42K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
568 |
366 |
$30K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,438 |
1,435 |
$16K |
| D0274 |
Bitewings - four radiographic images |
482 |
482 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
266 |
266 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
573 |
573 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
111 |
111 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
66 |
50 |
$4K |
| D0330 |
Panoramic radiographic image |
113 |
113 |
$4K |
| D0272 |
Bitewings - two radiographic images |
178 |
178 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
52 |
52 |
$691.80 |