| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
703 |
700 |
$33K |
| D0120 |
Periodic oral evaluation - established patient |
906 |
902 |
$22K |
| D1206 |
Topical application of fluoride varnish |
558 |
548 |
$13K |
| D1120 |
Prophylaxis - child |
299 |
289 |
$11K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
58 |
37 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
107 |
107 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
171 |
170 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
103 |
101 |
$4K |
| D2394 |
|
18 |
12 |
$3K |
| D0274 |
Bitewings - four radiographic images |
26 |
25 |
$701.40 |