| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,456 |
1,454 |
$64K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
796 |
529 |
$54K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
614 |
366 |
$32K |
| D0120 |
Periodic oral evaluation - established patient |
1,253 |
1,250 |
$31K |
| D1206 |
Topical application of fluoride varnish |
765 |
763 |
$22K |
| D0210 |
Intraoral - complete series of radiographic images |
454 |
453 |
$20K |
| D1208 |
Topical application of fluoride, excluding varnish |
614 |
613 |
$15K |
| D0274 |
Bitewings - four radiographic images |
942 |
942 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,013 |
1,011 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
224 |
224 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
1,210 |
1,203 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
102 |
102 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
28 |
25 |
$2K |