| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
956 |
946 |
$39K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,017 |
1,010 |
$35K |
| D0274 |
Bitewings - four radiographic images |
1,034 |
1,022 |
$30K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
162 |
95 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
541 |
529 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
214 |
209 |
$6K |
| D1120 |
Prophylaxis - child |
80 |
78 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
147 |
125 |
$2K |
| D1206 |
Topical application of fluoride varnish |
25 |
24 |
$456.22 |
| D0120 |
Periodic oral evaluation - established patient |
32 |
32 |
$421.27 |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$196.56 |