| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
568 |
557 |
$15K |
| D1110 |
Prophylaxis - adult |
222 |
217 |
$8K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
21 |
14 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
50 |
49 |
$2K |
| D1206 |
Topical application of fluoride varnish |
139 |
136 |
$2K |
| D1120 |
Prophylaxis - child |
75 |
72 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
49 |
43 |
$2K |
| D0274 |
Bitewings - four radiographic images |
38 |
37 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
36 |
34 |
$544.92 |
| D0272 |
Bitewings - two radiographic images |
16 |
16 |
$325.12 |
| D0230 |
Intraoral - periapical each additional radiographic image |
21 |
14 |
$238.58 |