| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
538 |
535 |
$25K |
| D0140 |
Limited oral evaluation - problem focused |
385 |
373 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
295 |
290 |
$15K |
| D0274 |
Bitewings - four radiographic images |
508 |
499 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
820 |
763 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
108 |
56 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
258 |
257 |
$6K |
| D0330 |
Panoramic radiographic image |
182 |
179 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
68 |
41 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
523 |
448 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$1K |
| D1206 |
Topical application of fluoride varnish |
17 |
17 |
$339.47 |