| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
810 |
799 |
$52K |
| D0120 |
Periodic oral evaluation - established patient |
835 |
828 |
$26K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
132 |
87 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
266 |
255 |
$14K |
| D0274 |
Bitewings - four radiographic images |
464 |
458 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
859 |
803 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
72 |
41 |
$7K |
| D1206 |
Topical application of fluoride varnish |
243 |
237 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
102 |
96 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
652 |
623 |
$5K |
| D1120 |
Prophylaxis - child |
86 |
86 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
16 |
13 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
83 |
83 |
$2K |
| D1330 |
|
29 |
29 |
$174.00 |