| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,385 |
2,382 |
$35K |
| D1110 |
Prophylaxis - adult |
2,011 |
2,007 |
$34K |
| D5761 |
|
378 |
377 |
$31K |
| D4355 |
|
769 |
768 |
$31K |
| D5760 |
|
245 |
245 |
$20K |
| D0274 |
Bitewings - four radiographic images |
1,507 |
1,503 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
646 |
645 |
$13K |
| D0210 |
Intraoral - complete series of radiographic images |
491 |
491 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
2,250 |
2,223 |
$8K |
| D1206 |
Topical application of fluoride varnish |
556 |
556 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
167 |
79 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,696 |
1,692 |
$5K |
| D1120 |
Prophylaxis - child |
133 |
133 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
81 |
81 |
$1K |
| D9110 |
|
78 |
78 |
$749.00 |