| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
97 |
97 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
77 |
77 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
93 |
92 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
27 |
15 |
$2K |
| D1206 |
Topical application of fluoride varnish |
97 |
97 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
16 |
12 |
$1K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
19 |
12 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
96 |
94 |
$1K |
| D4910 |
|
14 |
14 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
170 |
83 |
$737.10 |
| D1120 |
Prophylaxis - child |
13 |
12 |
$630.00 |
| D0272 |
Bitewings - two radiographic images |
53 |
51 |
$564.00 |
| D0120 |
Periodic oral evaluation - established patient |
83 |
82 |
$332.00 |