| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,112 |
1,058 |
$58K |
| D0274 |
Bitewings - four radiographic images |
924 |
894 |
$32K |
| D0220 |
Intraoral - periapical first radiographic image |
1,145 |
1,102 |
$17K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,208 |
1,009 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
654 |
622 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
276 |
275 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
26 |
26 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
25 |
12 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
29 |
28 |
$807.00 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$561.00 |