| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,160 |
1,005 |
$52K |
| D0120 |
Periodic oral evaluation - established patient |
1,129 |
980 |
$25K |
| D0210 |
Intraoral - complete series of radiographic images |
379 |
309 |
$22K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
292 |
148 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
549 |
475 |
$18K |
| D1206 |
Topical application of fluoride varnish |
715 |
620 |
$14K |
| D0274 |
Bitewings - four radiographic images |
407 |
365 |
$13K |
| D1120 |
Prophylaxis - child |
160 |
152 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
40 |
25 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
28 |
25 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
67 |
54 |
$690.38 |