| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
612 |
610 |
$28K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
256 |
161 |
$27K |
| D0120 |
Periodic oral evaluation - established patient |
602 |
601 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
158 |
109 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
286 |
286 |
$10K |
| D1120 |
Prophylaxis - child |
250 |
250 |
$9K |
| D1206 |
Topical application of fluoride varnish |
501 |
501 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
437 |
432 |
$6K |
| D0274 |
Bitewings - four radiographic images |
156 |
156 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
79 |
79 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
249 |
225 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
25 |
25 |
$1K |