| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,494 |
1,474 |
$37K |
| D0120 |
Periodic oral evaluation - established patient |
1,420 |
1,404 |
$34K |
| D0230 |
Intraoral - periapical each additional radiographic image |
658 |
653 |
$5K |
| D0274 |
Bitewings - four radiographic images |
487 |
481 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
58 |
37 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
908 |
894 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$315.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$243.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
56 |
54 |
$229.00 |