| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
728 |
724 |
$31K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
333 |
218 |
$22K |
| D1206 |
Topical application of fluoride varnish |
454 |
454 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
521 |
517 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
233 |
233 |
$5K |
| D0274 |
Bitewings - four radiographic images |
418 |
414 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
178 |
178 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
97 |
97 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
75 |
40 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
594 |
582 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
663 |
657 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
40 |
40 |
$2K |
| D1120 |
Prophylaxis - child |
32 |
32 |
$950.00 |
| D0603 |
|
14 |
14 |
$40.00 |