| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
677 |
677 |
$29K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
775 |
775 |
$27K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,332 |
1,332 |
$24K |
| D0274 |
Bitewings - four radiographic images |
613 |
613 |
$18K |
| D1120 |
Prophylaxis - child |
299 |
299 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
410 |
410 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
688 |
659 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
118 |
99 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
138 |
137 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
343 |
282 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
40 |
17 |
$3K |
| D0272 |
Bitewings - two radiographic images |
30 |
30 |
$614.85 |