| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
390 |
390 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
396 |
396 |
$18K |
| D1120 |
Prophylaxis - child |
468 |
467 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
664 |
662 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
616 |
600 |
$10K |
| D1206 |
Topical application of fluoride varnish |
346 |
346 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
65 |
37 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
490 |
345 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
173 |
172 |
$4K |
| D0274 |
Bitewings - four radiographic images |
95 |
95 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
59 |
59 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
26 |
26 |
$2K |
| D0272 |
Bitewings - two radiographic images |
43 |
42 |
$763.58 |