| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,706 |
3,704 |
$142K |
| D0120 |
Periodic oral evaluation - established patient |
3,380 |
3,376 |
$69K |
| D0274 |
Bitewings - four radiographic images |
2,925 |
2,924 |
$59K |
| D0210 |
Intraoral - complete series of radiographic images |
962 |
960 |
$38K |
| D0220 |
Intraoral - periapical first radiographic image |
2,744 |
2,741 |
$26K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
744 |
744 |
$16K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,926 |
2,926 |
$15K |
| D1208 |
Topical application of fluoride, excluding varnish |
837 |
835 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
98 |
66 |
$9K |
| D1120 |
Prophylaxis - child |
207 |
207 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
17 |
16 |
$1K |