| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
884 |
884 |
$25K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
839 |
838 |
$22K |
| D0120 |
Periodic oral evaluation - established patient |
785 |
783 |
$21K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
269 |
127 |
$13K |
| D1206 |
Topical application of fluoride varnish |
559 |
559 |
$9K |
| D1120 |
Prophylaxis - child |
336 |
336 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
236 |
236 |
$8K |
| D0274 |
Bitewings - four radiographic images |
557 |
557 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
1,413 |
1,409 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,226 |
1,224 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
368 |
368 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
77 |
45 |
$3K |
| D0272 |
Bitewings - two radiographic images |
172 |
172 |
$1K |
| D0603 |
|
71 |
71 |
$625.00 |
| D0140 |
Limited oral evaluation - problem focused |
26 |
26 |
$572.00 |