| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,306 |
1,305 |
$69K |
| D0120 |
Periodic oral evaluation - established patient |
2,351 |
2,351 |
$63K |
| D1120 |
Prophylaxis - child |
1,185 |
1,185 |
$46K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,629 |
1,629 |
$39K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
259 |
124 |
$24K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
177 |
95 |
$22K |
| D0274 |
Bitewings - four radiographic images |
576 |
576 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
930 |
927 |
$15K |
| D0210 |
Intraoral - complete series of radiographic images |
196 |
196 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,246 |
772 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
116 |
116 |
$5K |