| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
914 |
901 |
$49K |
| D0120 |
Periodic oral evaluation - established patient |
1,246 |
1,235 |
$35K |
| D1208 |
Topical application of fluoride, excluding varnish |
888 |
871 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
1,479 |
1,420 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
93 |
50 |
$13K |
| D1206 |
Topical application of fluoride varnish |
476 |
476 |
$13K |
| D0274 |
Bitewings - four radiographic images |
556 |
547 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
98 |
40 |
$10K |
| D1120 |
Prophylaxis - child |
201 |
201 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
151 |
143 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,014 |
966 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
118 |
113 |
$4K |
| D1330 |
|
212 |
211 |
$1K |