| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
742 |
724 |
$21K |
| D0140 |
Limited oral evaluation - problem focused |
812 |
693 |
$13K |
| D1320 |
|
575 |
565 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
388 |
377 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
221 |
220 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
949 |
826 |
$4K |
| D0274 |
Bitewings - four radiographic images |
235 |
225 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
38 |
38 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
291 |
256 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
20 |
13 |
$972.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
25 |
24 |
$360.00 |