| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,026 |
2,015 |
$31K |
| D0120 |
Periodic oral evaluation - established patient |
2,117 |
2,104 |
$29K |
| D0274 |
Bitewings - four radiographic images |
1,774 |
1,763 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
2,397 |
2,363 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,496 |
1,482 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
105 |
63 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
89 |
89 |
$884.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
81 |
77 |
$800.00 |
| D0210 |
Intraoral - complete series of radiographic images |
59 |
59 |
$772.00 |
| D0140 |
Limited oral evaluation - problem focused |
42 |
42 |
$314.00 |
| D1120 |
Prophylaxis - child |
63 |
63 |
$222.00 |
| D1206 |
Topical application of fluoride varnish |
29 |
29 |
$60.00 |