| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,940 |
1,914 |
$51K |
| D9630 |
|
2,650 |
2,610 |
$34K |
| D0210 |
Intraoral - complete series of radiographic images |
665 |
491 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
1,596 |
1,582 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
614 |
606 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
291 |
128 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
264 |
168 |
$12K |
| D1206 |
Topical application of fluoride varnish |
458 |
454 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
1,048 |
1,027 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
326 |
320 |
$5K |
| D0170 |
|
475 |
409 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
590 |
304 |
$3K |
| D1120 |
Prophylaxis - child |
80 |
80 |
$2K |
| D0274 |
Bitewings - four radiographic images |
272 |
266 |
$2K |
| D0330 |
Panoramic radiographic image |
52 |
51 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
58 |
58 |
$1K |