| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,310 |
2,050 |
$111K |
| D0120 |
Periodic oral evaluation - established patient |
2,420 |
2,153 |
$51K |
| D0220 |
Intraoral - periapical first radiographic image |
1,038 |
898 |
$15K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
181 |
81 |
$15K |
| D0274 |
Bitewings - four radiographic images |
392 |
340 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
442 |
387 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
782 |
650 |
$10K |
| D1120 |
Prophylaxis - child |
94 |
74 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
49 |
41 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
19 |
19 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
16 |
13 |
$554.00 |