| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
727 |
634 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
766 |
678 |
$11K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
189 |
43 |
$10K |
| D0274 |
Bitewings - four radiographic images |
586 |
522 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
118 |
45 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
249 |
216 |
$6K |
| D1120 |
Prophylaxis - child |
293 |
264 |
$5K |
| D2394 |
|
84 |
24 |
$4K |
| D1206 |
Topical application of fluoride varnish |
233 |
205 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
60 |
46 |
$835.46 |
| D0272 |
Bitewings - two radiographic images |
114 |
102 |
$800.00 |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
12 |
$600.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
49 |
40 |
$570.00 |
| D0220 |
Intraoral - periapical first radiographic image |
61 |
47 |
$205.00 |