| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
930 |
930 |
$51K |
| D0274 |
Bitewings - four radiographic images |
568 |
565 |
$19K |
| D1208 |
Topical application of fluoride, excluding varnish |
760 |
760 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
553 |
552 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
275 |
274 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
208 |
208 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
781 |
772 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
1,051 |
1,034 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
93 |
68 |
$8K |
| D4355 |
|
41 |
39 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
55 |
53 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
14 |
12 |
$1K |