| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
889 |
888 |
$39K |
| D0120 |
Periodic oral evaluation - established patient |
786 |
785 |
$19K |
| D1206 |
Topical application of fluoride varnish |
639 |
638 |
$19K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
163 |
106 |
$11K |
| D0210 |
Intraoral - complete series of radiographic images |
168 |
168 |
$8K |
| D0274 |
Bitewings - four radiographic images |
605 |
604 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
99 |
66 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
183 |
183 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
681 |
673 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
760 |
750 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
80 |
80 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
45 |
44 |
$2K |
| D1120 |
Prophylaxis - child |
12 |
12 |
$315.00 |