| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
615 |
613 |
$27K |
| D0120 |
Periodic oral evaluation - established patient |
573 |
572 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
447 |
446 |
$11K |
| D0210 |
Intraoral - complete series of radiographic images |
184 |
183 |
$8K |
| D1206 |
Topical application of fluoride varnish |
165 |
165 |
$5K |
| D0274 |
Bitewings - four radiographic images |
380 |
379 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
65 |
48 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
475 |
471 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
506 |
505 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
54 |
54 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
27 |
27 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
17 |
13 |
$935.00 |