| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,240 |
1,240 |
$43K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
447 |
209 |
$22K |
| D0120 |
Periodic oral evaluation - established patient |
1,158 |
1,158 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
1,874 |
1,793 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
339 |
339 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
121 |
64 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
681 |
681 |
$6K |
| D0274 |
Bitewings - four radiographic images |
942 |
942 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,425 |
1,406 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
98 |
53 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
143 |
143 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
147 |
146 |
$1K |
| D1320 |
|
101 |
101 |
$606.00 |
| D1120 |
Prophylaxis - child |
16 |
16 |
$412.80 |