| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,152 |
1,144 |
$95K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,450 |
1,444 |
$89K |
| D0120 |
Periodic oral evaluation - established patient |
1,110 |
1,101 |
$53K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,882 |
1,868 |
$23K |
| D0274 |
Bitewings - four radiographic images |
795 |
794 |
$17K |
| D1120 |
Prophylaxis - child |
505 |
501 |
$16K |
| D0230 |
Intraoral - periapical each additional radiographic image |
712 |
650 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
72 |
41 |
$4K |
| D0272 |
Bitewings - two radiographic images |
82 |
82 |
$984.00 |
| D0220 |
Intraoral - periapical first radiographic image |
54 |
52 |
$602.00 |