| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,417 |
2,417 |
$97K |
| D0210 |
Intraoral - complete series of radiographic images |
1,021 |
1,021 |
$36K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,419 |
1,419 |
$31K |
| D0274 |
Bitewings - four radiographic images |
995 |
995 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
986 |
986 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
1,322 |
1,319 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,130 |
1,130 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
190 |
190 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
35 |
25 |
$2K |
| D1120 |
Prophylaxis - child |
39 |
39 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
15 |
12 |
$1K |