| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,469 |
1,442 |
$41K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
274 |
136 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
1,051 |
1,038 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
422 |
411 |
$8K |
| D0274 |
Bitewings - four radiographic images |
694 |
686 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
67 |
67 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
495 |
478 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
82 |
78 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
512 |
267 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
41 |
41 |
$616.00 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$504.00 |