| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,836 |
2,817 |
$36K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,689 |
1,681 |
$31K |
| D0210 |
Intraoral - complete series of radiographic images |
1,072 |
1,064 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
1,563 |
1,548 |
$17K |
| D0274 |
Bitewings - four radiographic images |
1,557 |
1,544 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
2,203 |
2,188 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,965 |
1,945 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
101 |
81 |
$3K |
| D1120 |
Prophylaxis - child |
126 |
125 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
148 |
148 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
22 |
12 |
$480.00 |
| D0140 |
Limited oral evaluation - problem focused |
15 |
15 |
$204.00 |