| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
386 |
366 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
329 |
316 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
42 |
40 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
32 |
13 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
38 |
12 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
45 |
40 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
33 |
31 |
$1K |
| D0274 |
Bitewings - four radiographic images |
34 |
32 |
$1K |
| D1120 |
Prophylaxis - child |
22 |
20 |
$816.00 |
| D0220 |
Intraoral - periapical first radiographic image |
38 |
37 |
$516.00 |
| D1206 |
Topical application of fluoride varnish |
21 |
20 |
$442.00 |