| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,073 |
1,013 |
$40K |
| D0120 |
Periodic oral evaluation - established patient |
1,268 |
1,199 |
$31K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
181 |
98 |
$19K |
| D0274 |
Bitewings - four radiographic images |
498 |
467 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
1,006 |
935 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
648 |
608 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
589 |
553 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
136 |
128 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
119 |
112 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
24 |
16 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
14 |
12 |
$2K |
| D0330 |
Panoramic radiographic image |
39 |
35 |
$2K |
| D1206 |
Topical application of fluoride varnish |
174 |
157 |
$2K |
| D1120 |
Prophylaxis - child |
12 |
12 |
$358.56 |