| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
786 |
785 |
$36K |
| D0120 |
Periodic oral evaluation - established patient |
969 |
967 |
$27K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
406 |
171 |
$23K |
| D1206 |
Topical application of fluoride varnish |
977 |
974 |
$18K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
190 |
119 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
589 |
580 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
173 |
172 |
$6K |
| D0274 |
Bitewings - four radiographic images |
217 |
217 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
509 |
348 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
124 |
112 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
37 |
37 |
$2K |
| D0602 |
|
182 |
182 |
$2K |
| D1120 |
Prophylaxis - child |
41 |
41 |
$2K |
| D1999 |
|
128 |
81 |
$896.00 |
| D0601 |
|
77 |
77 |
$748.00 |