| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
458 |
452 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
173 |
173 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
168 |
163 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
68 |
67 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
612 |
604 |
$862.20 |
| D1330 |
|
624 |
617 |
$857.84 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
14 |
$341.48 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
25 |
12 |
$268.44 |
| D0220 |
Intraoral - periapical first radiographic image |
27 |
27 |
$68.00 |