| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
789 |
785 |
$38K |
| D0120 |
Periodic oral evaluation - established patient |
908 |
905 |
$24K |
| D0274 |
Bitewings - four radiographic images |
402 |
402 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
275 |
273 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
630 |
621 |
$10K |
| D1120 |
Prophylaxis - child |
215 |
215 |
$9K |
| D1206 |
Topical application of fluoride varnish |
263 |
262 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
309 |
309 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
492 |
408 |
$4K |
| D0330 |
Panoramic radiographic image |
65 |
65 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
17 |
12 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
26 |
24 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
14 |
$895.80 |