| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,118 |
1,041 |
$46K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
469 |
318 |
$34K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
327 |
215 |
$28K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
716 |
687 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
898 |
828 |
$20K |
| D0210 |
Intraoral - complete series of radiographic images |
204 |
199 |
$17K |
| D0140 |
Limited oral evaluation - problem focused |
405 |
378 |
$12K |
| D0274 |
Bitewings - four radiographic images |
428 |
398 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
383 |
351 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
864 |
799 |
$6K |
| D1120 |
Prophylaxis - child |
136 |
126 |
$4K |
| D0330 |
Panoramic radiographic image |
64 |
59 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
306 |
175 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
18 |
13 |
$938.38 |