| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
343 |
333 |
$17K |
| D1120 |
Prophylaxis - child |
287 |
274 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
447 |
438 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
334 |
324 |
$9K |
| D0274 |
Bitewings - four radiographic images |
231 |
224 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
69 |
31 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
115 |
113 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
265 |
254 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
70 |
70 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
28 |
15 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
194 |
148 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
31 |
31 |
$2K |
| D0272 |
Bitewings - two radiographic images |
24 |
24 |
$720.00 |