| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
547 |
546 |
$15K |
| D1120 |
Prophylaxis - child |
270 |
270 |
$11K |
| D1110 |
Prophylaxis - adult |
178 |
178 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
67 |
47 |
$7K |
| D1206 |
Topical application of fluoride varnish |
290 |
290 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
298 |
294 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
49 |
48 |
$4K |
| D1352 |
|
49 |
14 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
51 |
49 |
$2K |
| D0274 |
Bitewings - four radiographic images |
60 |
59 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
222 |
143 |
$2K |
| D4355 |
|
15 |
14 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
17 |
17 |
$659.97 |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$279.14 |