| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,126 |
1,122 |
$41K |
| D9310 |
|
560 |
556 |
$27K |
| D0220 |
Intraoral - periapical first radiographic image |
1,740 |
1,698 |
$16K |
| D0274 |
Bitewings - four radiographic images |
877 |
877 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
711 |
711 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
235 |
171 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,393 |
1,378 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
580 |
578 |
$12K |
| D0330 |
Panoramic radiographic image |
146 |
146 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
280 |
277 |
$3K |
| D1120 |
Prophylaxis - child |
97 |
97 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
37 |
31 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
167 |
167 |
$2K |