| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
581 |
575 |
$23K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
398 |
394 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
573 |
569 |
$12K |
| D0274 |
Bitewings - four radiographic images |
524 |
523 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,833 |
709 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
117 |
73 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
70 |
70 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
836 |
822 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
49 |
27 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
90 |
87 |
$3K |
| D1206 |
Topical application of fluoride varnish |
137 |
137 |
$3K |
| D1120 |
Prophylaxis - child |
74 |
74 |
$2K |