| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,448 |
1,443 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
1,211 |
1,207 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
458 |
458 |
$11K |
| D0274 |
Bitewings - four radiographic images |
1,061 |
1,057 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
170 |
79 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
1,676 |
1,664 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,545 |
1,539 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
275 |
275 |
$3K |
| D1120 |
Prophylaxis - child |
206 |
206 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
100 |
100 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
70 |
28 |
$2K |