| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,286 |
1,286 |
$63K |
| D0120 |
Periodic oral evaluation - established patient |
1,763 |
1,761 |
$45K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
307 |
185 |
$36K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
310 |
177 |
$29K |
| D1120 |
Prophylaxis - child |
640 |
640 |
$25K |
| D1206 |
Topical application of fluoride varnish |
910 |
910 |
$22K |
| D0220 |
Intraoral - periapical first radiographic image |
853 |
841 |
$14K |
| D0274 |
Bitewings - four radiographic images |
346 |
345 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,038 |
568 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
176 |
176 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
117 |
113 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
56 |
53 |
$4K |