| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
341 |
340 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
619 |
617 |
$16K |
| D1120 |
Prophylaxis - child |
268 |
267 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
578 |
569 |
$9K |
| D1206 |
Topical application of fluoride varnish |
249 |
248 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
41 |
26 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
506 |
425 |
$4K |
| D0274 |
Bitewings - four radiographic images |
131 |
131 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
91 |
90 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
77 |
75 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
86 |
86 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
27 |
27 |
$2K |