| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
224 |
216 |
$9K |
| D0274 |
Bitewings - four radiographic images |
271 |
267 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
277 |
268 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
87 |
49 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
162 |
161 |
$4K |
| D1120 |
Prophylaxis - child |
98 |
96 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
457 |
430 |
$3K |
| D1206 |
Topical application of fluoride varnish |
196 |
192 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
373 |
343 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
66 |
61 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
23 |
13 |
$858.16 |