| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,065 |
1,064 |
$47K |
| D0120 |
Periodic oral evaluation - established patient |
1,327 |
1,327 |
$33K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
453 |
275 |
$31K |
| D1208 |
Topical application of fluoride, excluding varnish |
688 |
688 |
$17K |
| D1206 |
Topical application of fluoride varnish |
419 |
418 |
$13K |
| D1120 |
Prophylaxis - child |
264 |
264 |
$12K |
| D0274 |
Bitewings - four radiographic images |
768 |
767 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,330 |
1,327 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
1,458 |
1,446 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
95 |
88 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
74 |
44 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
112 |
112 |
$3K |
| D0272 |
Bitewings - two radiographic images |
211 |
211 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$585.00 |