| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,106 |
1,106 |
$48K |
| D0120 |
Periodic oral evaluation - established patient |
1,117 |
1,117 |
$25K |
| D0274 |
Bitewings - four radiographic images |
469 |
469 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
239 |
130 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
728 |
728 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
874 |
872 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
70 |
47 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
114 |
114 |
$4K |
| D1120 |
Prophylaxis - child |
93 |
93 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
101 |
101 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
158 |
157 |
$2K |
| D1206 |
Topical application of fluoride varnish |
40 |
40 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
34 |
34 |
$453.60 |