| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
365 |
365 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
491 |
490 |
$13K |
| D1206 |
Topical application of fluoride varnish |
530 |
529 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
544 |
487 |
$9K |
| D1110 |
Prophylaxis - adult |
113 |
112 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
418 |
245 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
23 |
13 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
27 |
26 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
15 |
15 |
$1K |
| D0274 |
Bitewings - four radiographic images |
28 |
28 |
$920.50 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$539.00 |