| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
828 |
822 |
$68K |
| D0120 |
Periodic oral evaluation - established patient |
520 |
518 |
$29K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
378 |
378 |
$21K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,311 |
1,304 |
$17K |
| D0210 |
Intraoral - complete series of radiographic images |
279 |
279 |
$12K |
| D0350 |
|
847 |
324 |
$7K |
| D0274 |
Bitewings - four radiographic images |
292 |
291 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
81 |
41 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
983 |
505 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
47 |
13 |
$3K |