| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
4,824 |
4,811 |
$146K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,859 |
2,858 |
$57K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,796 |
4,783 |
$53K |
| D0120 |
Periodic oral evaluation - established patient |
2,316 |
2,312 |
$43K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
260 |
211 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
192 |
161 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
76 |
71 |
$607.35 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$0.00 |