| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
857 |
855 |
$37K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
323 |
215 |
$22K |
| D1206 |
Topical application of fluoride varnish |
699 |
697 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
809 |
807 |
$20K |
| D0210 |
Intraoral - complete series of radiographic images |
158 |
158 |
$7K |
| D0274 |
Bitewings - four radiographic images |
582 |
579 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
96 |
60 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
738 |
733 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
86 |
86 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
618 |
611 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
110 |
108 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
28 |
24 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
14 |
14 |
$300.00 |