| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,822 |
1,736 |
$99K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
672 |
385 |
$53K |
| D0120 |
Periodic oral evaluation - established patient |
1,698 |
1,624 |
$40K |
| D0274 |
Bitewings - four radiographic images |
683 |
646 |
$24K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
296 |
288 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
432 |
422 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
173 |
91 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
615 |
586 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
443 |
376 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
71 |
69 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
40 |
26 |
$4K |
| D1120 |
Prophylaxis - child |
65 |
64 |
$4K |