| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,798 |
1,774 |
$65K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,259 |
3,236 |
$58K |
| D1120 |
Prophylaxis - child |
1,979 |
1,968 |
$58K |
| D0120 |
Periodic oral evaluation - established patient |
3,414 |
3,383 |
$57K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
552 |
308 |
$36K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
327 |
158 |
$25K |
| D0274 |
Bitewings - four radiographic images |
914 |
899 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
418 |
415 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
571 |
554 |
$4K |
| D0272 |
Bitewings - two radiographic images |
138 |
138 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
259 |
194 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
113 |
112 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
29 |
28 |
$1K |