| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0140 |
Limited oral evaluation - problem focused |
1,211 |
1,181 |
$44K |
| D1110 |
Prophylaxis - adult |
526 |
526 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
673 |
673 |
$25K |
| D0274 |
Bitewings - four radiographic images |
409 |
409 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
1,054 |
1,023 |
$17K |
| D1120 |
Prophylaxis - child |
299 |
298 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
94 |
58 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
89 |
89 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
133 |
133 |
$6K |
| D1206 |
Topical application of fluoride varnish |
313 |
313 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
42 |
27 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
132 |
106 |
$2K |