| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
701 |
691 |
$29K |
| D0120 |
Periodic oral evaluation - established patient |
909 |
904 |
$21K |
| D0274 |
Bitewings - four radiographic images |
259 |
256 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
557 |
542 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
162 |
156 |
$6K |
| D1120 |
Prophylaxis - child |
175 |
172 |
$6K |
| D1206 |
Topical application of fluoride varnish |
306 |
303 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
132 |
132 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
16 |
13 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
73 |
73 |
$2K |