| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
410 |
409 |
$18K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
247 |
139 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
366 |
366 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
269 |
269 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
123 |
61 |
$6K |
| D1206 |
Topical application of fluoride varnish |
164 |
164 |
$5K |
| D0274 |
Bitewings - four radiographic images |
287 |
287 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
58 |
58 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
383 |
383 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
364 |
363 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
63 |
63 |
$2K |
| D0603 |
|
36 |
36 |
$250.00 |