| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,161 |
3,104 |
$165K |
| D0274 |
Bitewings - four radiographic images |
2,937 |
2,895 |
$83K |
| D0120 |
Periodic oral evaluation - established patient |
2,424 |
2,383 |
$53K |
| D0330 |
Panoramic radiographic image |
325 |
321 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
897 |
836 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
268 |
266 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
200 |
108 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
116 |
76 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
256 |
244 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
79 |
79 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
26 |
26 |
$1K |