| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
448 |
446 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
273 |
143 |
$11K |
| D0210 |
Intraoral - complete series of radiographic images |
212 |
210 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
216 |
215 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
283 |
280 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
129 |
74 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
15 |
12 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
273 |
263 |
$610.82 |
| D1206 |
Topical application of fluoride varnish |
328 |
326 |
$489.30 |
| D0274 |
Bitewings - four radiographic images |
188 |
186 |
$443.00 |
| D0220 |
Intraoral - periapical first radiographic image |
288 |
282 |
$86.83 |
| D1330 |
|
446 |
443 |
$78.39 |
| D1208 |
Topical application of fluoride, excluding varnish |
14 |
14 |
$33.05 |