| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
833 |
822 |
$25K |
| D1110 |
Prophylaxis - adult |
691 |
686 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
1,263 |
1,248 |
$20K |
| D1208 |
Topical application of fluoride, excluding varnish |
647 |
637 |
$12K |
| D0274 |
Bitewings - four radiographic images |
524 |
520 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
328 |
320 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
790 |
403 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
586 |
564 |
$5K |
| D1206 |
Topical application of fluoride varnish |
234 |
234 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
33 |
13 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
39 |
36 |
$975.84 |