| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
238 |
212 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
301 |
274 |
$2K |
| D0274 |
Bitewings - four radiographic images |
91 |
82 |
$921.45 |
| D1208 |
Topical application of fluoride, excluding varnish |
200 |
179 |
$738.87 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
141 |
116 |
$639.00 |
| D1120 |
Prophylaxis - child |
78 |
71 |
$483.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
104 |
57 |
$436.50 |
| D0210 |
Intraoral - complete series of radiographic images |
76 |
54 |
$361.25 |
| D0140 |
Limited oral evaluation - problem focused |
42 |
37 |
$333.72 |
| D0220 |
Intraoral - periapical first radiographic image |
36 |
33 |
$66.25 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
35 |
24 |
$55.50 |