| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,167 |
1,163 |
$48K |
| D0140 |
Limited oral evaluation - problem focused |
665 |
642 |
$21K |
| D0220 |
Intraoral - periapical first radiographic image |
1,641 |
1,570 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
762 |
759 |
$19K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,143 |
725 |
$9K |
| D2394 |
|
47 |
28 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
92 |
51 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
129 |
129 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
63 |
63 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
107 |
107 |
$3K |
| D0274 |
Bitewings - four radiographic images |
51 |
51 |
$1K |
| D1120 |
Prophylaxis - child |
28 |
28 |
$1K |