| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,569 |
1,452 |
$68K |
| D0120 |
Periodic oral evaluation - established patient |
1,060 |
979 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
427 |
374 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
194 |
180 |
$11K |
| D0274 |
Bitewings - four radiographic images |
325 |
298 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
43 |
28 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
81 |
68 |
$855.17 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
20 |
12 |
$823.41 |
| D1208 |
Topical application of fluoride, excluding varnish |
29 |
26 |
$413.52 |
| D0140 |
Limited oral evaluation - problem focused |
16 |
12 |
$395.95 |
| D1999 |
|
23 |
19 |
$0.00 |