| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,066 |
1,044 |
$54K |
| D0120 |
Periodic oral evaluation - established patient |
1,385 |
1,352 |
$34K |
| D1120 |
Prophylaxis - child |
597 |
584 |
$29K |
| D0274 |
Bitewings - four radiographic images |
724 |
707 |
$26K |
| D1208 |
Topical application of fluoride, excluding varnish |
812 |
789 |
$23K |
| D0140 |
Limited oral evaluation - problem focused |
274 |
260 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
610 |
582 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
183 |
177 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
462 |
379 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
62 |
25 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
67 |
43 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
51 |
51 |
$3K |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$360.00 |