| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
529 |
525 |
$10K |
| D1120 |
Prophylaxis - child |
669 |
664 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
633 |
625 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
565 |
561 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
577 |
571 |
$5K |
| D0274 |
Bitewings - four radiographic images |
468 |
465 |
$5K |
| D0272 |
Bitewings - two radiographic images |
303 |
298 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
119 |
117 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
45 |
37 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
13 |
12 |
$832.26 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
13 |
12 |
$645.19 |
| D0220 |
Intraoral - periapical first radiographic image |
62 |
61 |
$408.30 |