| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,810 |
1,733 |
$90K |
| D0120 |
Periodic oral evaluation - established patient |
1,540 |
1,484 |
$32K |
| D0274 |
Bitewings - four radiographic images |
400 |
381 |
$13K |
| D0140 |
Limited oral evaluation - problem focused |
199 |
181 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
55 |
52 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
270 |
248 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
43 |
41 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
23 |
12 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
28 |
28 |
$812.00 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$612.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
24 |
12 |
$250.00 |