| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
454 |
454 |
$22K |
| D0120 |
Periodic oral evaluation - established patient |
755 |
755 |
$19K |
| D1206 |
Topical application of fluoride varnish |
880 |
880 |
$19K |
| D1120 |
Prophylaxis - child |
436 |
436 |
$17K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
131 |
89 |
$16K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
56 |
37 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
224 |
222 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
81 |
81 |
$3K |
| D0274 |
Bitewings - four radiographic images |
75 |
75 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
152 |
146 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$574.00 |
| D0272 |
Bitewings - two radiographic images |
26 |
26 |
$562.00 |