| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,544 |
1,538 |
$79K |
| D0120 |
Periodic oral evaluation - established patient |
1,278 |
1,274 |
$33K |
| D0274 |
Bitewings - four radiographic images |
232 |
231 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
212 |
212 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
62 |
62 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
36 |
26 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
15 |
12 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
66 |
65 |
$769.76 |
| D0140 |
Limited oral evaluation - problem focused |
51 |
51 |
$732.90 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$494.05 |
| D1208 |
Topical application of fluoride, excluding varnish |
25 |
25 |
$355.25 |