| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,005 |
996 |
$47K |
| D0120 |
Periodic oral evaluation - established patient |
1,839 |
1,828 |
$36K |
| D1120 |
Prophylaxis - child |
927 |
925 |
$30K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
322 |
161 |
$29K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
292 |
159 |
$21K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,004 |
1,002 |
$20K |
| D0274 |
Bitewings - four radiographic images |
594 |
590 |
$16K |
| D8670 |
Periodic orthodontic treatment visit |
37 |
37 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
163 |
163 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
110 |
105 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
100 |
99 |
$2K |
| D0330 |
Panoramic radiographic image |
14 |
14 |
$755.86 |
| D0220 |
Intraoral - periapical first radiographic image |
49 |
41 |
$514.28 |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$261.95 |