| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
724 |
721 |
$31K |
| D0120 |
Periodic oral evaluation - established patient |
581 |
578 |
$14K |
| D1206 |
Topical application of fluoride varnish |
383 |
381 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
122 |
71 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
235 |
235 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
110 |
110 |
$5K |
| D0274 |
Bitewings - four radiographic images |
384 |
381 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
65 |
44 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
475 |
468 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
546 |
541 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
57 |
57 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
27 |
27 |
$1K |