| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,650 |
1,650 |
$57K |
| D0210 |
Intraoral - complete series of radiographic images |
1,493 |
1,488 |
$28K |
| D0120 |
Periodic oral evaluation - established patient |
1,338 |
1,338 |
$27K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,101 |
1,092 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
677 |
676 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
1,188 |
1,183 |
$12K |
| D1120 |
Prophylaxis - child |
260 |
260 |
$8K |
| D0274 |
Bitewings - four radiographic images |
299 |
299 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
159 |
77 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
286 |
286 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
302 |
271 |
$3K |
| D0272 |
Bitewings - two radiographic images |
111 |
111 |
$1K |