| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,288 |
1,186 |
$54K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
276 |
133 |
$30K |
| D1206 |
Topical application of fluoride varnish |
1,638 |
1,507 |
$26K |
| D0120 |
Periodic oral evaluation - established patient |
974 |
912 |
$22K |
| D0210 |
Intraoral - complete series of radiographic images |
342 |
319 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
432 |
398 |
$16K |
| D0274 |
Bitewings - four radiographic images |
287 |
265 |
$7K |
| D1120 |
Prophylaxis - child |
100 |
91 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
22 |
12 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
29 |
28 |
$1K |
| D0330 |
Panoramic radiographic image |
17 |
12 |
$600.00 |
| D0220 |
Intraoral - periapical first radiographic image |
14 |
13 |
$246.00 |