| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
914 |
881 |
$48K |
| D0120 |
Periodic oral evaluation - established patient |
1,095 |
1,069 |
$30K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,136 |
1,118 |
$26K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
481 |
458 |
$21K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
187 |
82 |
$20K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
119 |
61 |
$16K |
| D0210 |
Intraoral - complete series of radiographic images |
110 |
110 |
$6K |
| D0274 |
Bitewings - four radiographic images |
270 |
257 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
108 |
106 |
$5K |
| D1120 |
Prophylaxis - child |
63 |
63 |
$3K |
| D0330 |
Panoramic radiographic image |
25 |
25 |
$1K |
| D1330 |
|
158 |
156 |
$936.00 |
| D0220 |
Intraoral - periapical first radiographic image |
25 |
25 |
$246.25 |