| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,084 |
1,065 |
$36K |
| D0120 |
Periodic oral evaluation - established patient |
694 |
691 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
662 |
641 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
262 |
190 |
$14K |
| D0274 |
Bitewings - four radiographic images |
691 |
681 |
$14K |
| D0210 |
Intraoral - complete series of radiographic images |
402 |
387 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
201 |
133 |
$8K |
| D1120 |
Prophylaxis - child |
229 |
225 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
642 |
622 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
394 |
388 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
134 |
130 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
100 |
92 |
$465.66 |