| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,402 |
2,396 |
$66K |
| D0120 |
Periodic oral evaluation - established patient |
1,795 |
1,790 |
$26K |
| D0210 |
Intraoral - complete series of radiographic images |
801 |
798 |
$21K |
| D0274 |
Bitewings - four radiographic images |
1,585 |
1,581 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
2,316 |
2,282 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,014 |
1,012 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
297 |
191 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,261 |
1,241 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
787 |
781 |
$7K |
| D1120 |
Prophylaxis - child |
92 |
92 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
37 |
25 |
$965.57 |
| D1208 |
Topical application of fluoride, excluding varnish |
90 |
90 |
$825.87 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$188.50 |