| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
826 |
813 |
$33K |
| D0210 |
Intraoral - complete series of radiographic images |
206 |
199 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
490 |
489 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
352 |
308 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
482 |
446 |
$6K |
| D1206 |
Topical application of fluoride varnish |
268 |
268 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
332 |
293 |
$3K |
| D0274 |
Bitewings - four radiographic images |
126 |
126 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
23 |
13 |
$2K |
| D1120 |
Prophylaxis - child |
13 |
13 |
$435.76 |
| D0230 |
Intraoral - periapical each additional radiographic image |
26 |
13 |
$268.32 |