| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
712 |
699 |
$46K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,656 |
1,634 |
$38K |
| D0120 |
Periodic oral evaluation - established patient |
1,010 |
1,005 |
$31K |
| D1120 |
Prophylaxis - child |
588 |
581 |
$26K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
397 |
387 |
$21K |
| D0210 |
Intraoral - complete series of radiographic images |
270 |
260 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
140 |
57 |
$14K |
| D0274 |
Bitewings - four radiographic images |
304 |
303 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
16 |
12 |
$2K |
| D1330 |
|
190 |
189 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
111 |
84 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
14 |
14 |
$661.64 |