| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
401 |
399 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
330 |
327 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
103 |
68 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
237 |
236 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
98 |
98 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
67 |
66 |
$3K |
| D0274 |
Bitewings - four radiographic images |
216 |
215 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
66 |
66 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
352 |
343 |
$2K |
| D1206 |
Topical application of fluoride varnish |
43 |
43 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
23 |
12 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
289 |
287 |
$1K |