| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
341 |
335 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
352 |
342 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
474 |
460 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
44 |
24 |
$6K |
| D0274 |
Bitewings - four radiographic images |
163 |
162 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
42 |
41 |
$3K |
| D4910 |
|
42 |
36 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
169 |
166 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
14 |
12 |
$459.34 |
| D0230 |
Intraoral - periapical each additional radiographic image |
12 |
12 |
$295.68 |
| D1206 |
Topical application of fluoride varnish |
13 |
13 |
$218.27 |