| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
95 |
95 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
83 |
40 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
50 |
49 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
26 |
12 |
$1K |
| D9999 |
Unspecified adjunctive procedure, by report |
13 |
13 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
15 |
15 |
$659.00 |
| D0220 |
Intraoral - periapical first radiographic image |
125 |
122 |
$644.00 |
| D1120 |
Prophylaxis - child |
14 |
14 |
$441.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
17 |
14 |
$351.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
84 |
82 |
$183.15 |