| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,407 |
1,370 |
$50K |
| D0120 |
Periodic oral evaluation - established patient |
1,739 |
1,708 |
$42K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,110 |
2,068 |
$42K |
| D0210 |
Intraoral - complete series of radiographic images |
538 |
522 |
$35K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
279 |
157 |
$21K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
303 |
172 |
$20K |
| D0140 |
Limited oral evaluation - problem focused |
681 |
640 |
$19K |
| D0274 |
Bitewings - four radiographic images |
487 |
474 |
$16K |
| D1120 |
Prophylaxis - child |
298 |
295 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
57 |
55 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
41 |
41 |
$518.89 |