| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,352 |
1,345 |
$118K |
| D0120 |
Periodic oral evaluation - established patient |
616 |
612 |
$41K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
597 |
595 |
$38K |
| D0210 |
Intraoral - complete series of radiographic images |
394 |
394 |
$19K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,146 |
1,139 |
$16K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
213 |
151 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
204 |
94 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,908 |
847 |
$8K |
| D0274 |
Bitewings - four radiographic images |
142 |
142 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
25 |
16 |
$2K |