| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
992 |
980 |
$55K |
| D0120 |
Periodic oral evaluation - established patient |
1,025 |
1,016 |
$25K |
| D0220 |
Intraoral - periapical first radiographic image |
811 |
774 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
892 |
445 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
117 |
45 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
132 |
128 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
51 |
16 |
$4K |
| D0274 |
Bitewings - four radiographic images |
74 |
73 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
85 |
85 |
$2K |
| D1120 |
Prophylaxis - child |
13 |
13 |
$663.00 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$336.00 |