| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
739 |
734 |
$30K |
| D0120 |
Periodic oral evaluation - established patient |
693 |
687 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
459 |
456 |
$13K |
| D0274 |
Bitewings - four radiographic images |
467 |
462 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
313 |
302 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
303 |
303 |
$5K |
| D1120 |
Prophylaxis - child |
207 |
207 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
646 |
631 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
591 |
263 |
$3K |
| D1206 |
Topical application of fluoride varnish |
92 |
91 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
26 |
26 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
22 |
14 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
14 |
13 |
$716.94 |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$130.00 |