| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
447 |
434 |
$27K |
| D1208 |
Topical application of fluoride, excluding varnish |
912 |
892 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
620 |
604 |
$20K |
| D1120 |
Prophylaxis - child |
306 |
306 |
$13K |
| D0274 |
Bitewings - four radiographic images |
219 |
206 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
81 |
81 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
66 |
25 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
37 |
37 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$2K |
| D0330 |
Panoramic radiographic image |
17 |
17 |
$2K |
| D1206 |
Topical application of fluoride varnish |
35 |
35 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
26 |
24 |
$533.10 |