| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,641 |
1,639 |
$72K |
| D0120 |
Periodic oral evaluation - established patient |
1,856 |
1,855 |
$46K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
568 |
351 |
$39K |
| D1208 |
Topical application of fluoride, excluding varnish |
995 |
994 |
$25K |
| D1206 |
Topical application of fluoride varnish |
752 |
751 |
$23K |
| D0274 |
Bitewings - four radiographic images |
1,186 |
1,183 |
$14K |
| D1120 |
Prophylaxis - child |
289 |
289 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,850 |
1,846 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
2,047 |
2,035 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
152 |
151 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
36 |
28 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
61 |
59 |
$3K |
| D0272 |
Bitewings - two radiographic images |
147 |
147 |
$1K |
| D4355 |
|
12 |
12 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$540.00 |