| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,705 |
1,666 |
$58K |
| D0120 |
Periodic oral evaluation - established patient |
2,435 |
2,367 |
$43K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,192 |
2,113 |
$32K |
| D1120 |
Prophylaxis - child |
999 |
948 |
$27K |
| D0274 |
Bitewings - four radiographic images |
928 |
893 |
$22K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
216 |
137 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
149 |
100 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
224 |
207 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
24 |
24 |
$640.57 |
| D0220 |
Intraoral - periapical first radiographic image |
62 |
56 |
$578.45 |
| D0272 |
Bitewings - two radiographic images |
15 |
13 |
$300.96 |
| D0603 |
|
25 |
25 |
$120.00 |