| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
478 |
473 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
583 |
576 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
673 |
656 |
$6K |
| D1120 |
Prophylaxis - child |
108 |
105 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
357 |
350 |
$3K |
| D1206 |
Topical application of fluoride varnish |
160 |
159 |
$3K |
| D0274 |
Bitewings - four radiographic images |
117 |
115 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
61 |
61 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
24 |
17 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
29 |
29 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
13 |
12 |
$373.30 |