| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
723 |
721 |
$38K |
| D0120 |
Periodic oral evaluation - established patient |
755 |
753 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
748 |
730 |
$12K |
| D0272 |
Bitewings - two radiographic images |
448 |
446 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
549 |
501 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
145 |
141 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
182 |
181 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
59 |
26 |
$4K |
| D9110 |
|
89 |
89 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
43 |
24 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
28 |
28 |
$1K |
| D1120 |
Prophylaxis - child |
12 |
12 |
$612.00 |