| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,275 |
1,261 |
$45K |
| D0120 |
Periodic oral evaluation - established patient |
2,320 |
2,267 |
$43K |
| D1206 |
Topical application of fluoride varnish |
1,445 |
1,409 |
$24K |
| D1120 |
Prophylaxis - child |
728 |
703 |
$21K |
| D1208 |
Topical application of fluoride, excluding varnish |
359 |
346 |
$5K |
| D0274 |
Bitewings - four radiographic images |
194 |
189 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
30 |
24 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
119 |
114 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
37 |
36 |
$904.23 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$376.99 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$281.14 |