| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,264 |
1,261 |
$55K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
528 |
360 |
$35K |
| D0120 |
Periodic oral evaluation - established patient |
1,144 |
1,140 |
$28K |
| D1206 |
Topical application of fluoride varnish |
911 |
906 |
$26K |
| D0210 |
Intraoral - complete series of radiographic images |
274 |
274 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
200 |
148 |
$10K |
| D0274 |
Bitewings - four radiographic images |
858 |
854 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
351 |
351 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
169 |
167 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,053 |
1,031 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
1,171 |
1,165 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
79 |
79 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
16 |
12 |
$1K |
| D1310 |
|
30 |
30 |
$388.50 |
| D1330 |
|
26 |
26 |
$318.50 |
| D0603 |
|
26 |
26 |
$210.00 |
| D1320 |
|
13 |
13 |
$10.00 |