| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
820 |
803 |
$26K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
943 |
657 |
$25K |
| D0274 |
Bitewings - four radiographic images |
682 |
663 |
$19K |
| D0140 |
Limited oral evaluation - problem focused |
581 |
546 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
713 |
700 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
834 |
799 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
139 |
138 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
242 |
237 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
53 |
12 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
18 |
13 |
$1K |
| D1120 |
Prophylaxis - child |
12 |
12 |
$540.96 |
| D0230 |
Intraoral - periapical each additional radiographic image |
55 |
27 |
$490.96 |