| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,530 |
1,530 |
$68K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
685 |
465 |
$46K |
| D0120 |
Periodic oral evaluation - established patient |
1,415 |
1,414 |
$35K |
| D1206 |
Topical application of fluoride varnish |
1,091 |
1,091 |
$33K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
433 |
294 |
$23K |
| D0210 |
Intraoral - complete series of radiographic images |
306 |
305 |
$14K |
| D0274 |
Bitewings - four radiographic images |
949 |
948 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
360 |
359 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
1,202 |
1,198 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
948 |
946 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
59 |
59 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
38 |
37 |
$900.00 |