| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,964 |
1,951 |
$89K |
| D0120 |
Periodic oral evaluation - established patient |
1,727 |
1,718 |
$41K |
| D0274 |
Bitewings - four radiographic images |
755 |
753 |
$23K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
157 |
92 |
$21K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
165 |
107 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
407 |
406 |
$16K |
| D0210 |
Intraoral - complete series of radiographic images |
57 |
56 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
122 |
110 |
$4K |
| D1206 |
Topical application of fluoride varnish |
210 |
205 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
234 |
218 |
$3K |
| D2950 |
|
14 |
14 |
$1K |
| D1120 |
Prophylaxis - child |
12 |
12 |
$377.16 |