| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
947 |
947 |
$48K |
| D0120 |
Periodic oral evaluation - established patient |
1,774 |
1,773 |
$47K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
260 |
165 |
$31K |
| D1206 |
Topical application of fluoride varnish |
1,117 |
1,117 |
$27K |
| D1120 |
Prophylaxis - child |
661 |
661 |
$26K |
| D0274 |
Bitewings - four radiographic images |
703 |
703 |
$24K |
| D0220 |
Intraoral - periapical first radiographic image |
286 |
282 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
23 |
12 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
38 |
38 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
61 |
61 |
$2K |
| D0330 |
Panoramic radiographic image |
14 |
14 |
$935.67 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
17 |
17 |
$760.37 |
| D0230 |
Intraoral - periapical each additional radiographic image |
60 |
59 |
$592.49 |