| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,534 |
1,096 |
$55K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,198 |
828 |
$42K |
| D0210 |
Intraoral - complete series of radiographic images |
909 |
750 |
$28K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
378 |
138 |
$23K |
| D0274 |
Bitewings - four radiographic images |
1,048 |
591 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
732 |
556 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
1,008 |
716 |
$7K |
| D0330 |
Panoramic radiographic image |
195 |
148 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
776 |
579 |
$4K |
| D0272 |
Bitewings - two radiographic images |
28 |
26 |
$496.76 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$385.22 |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$310.40 |