| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
331 |
317 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
549 |
523 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
143 |
142 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
55 |
15 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
164 |
152 |
$3K |
| D1120 |
Prophylaxis - child |
100 |
98 |
$2K |
| D0274 |
Bitewings - four radiographic images |
80 |
78 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
19 |
13 |
$918.00 |
| D0140 |
Limited oral evaluation - problem focused |
27 |
26 |
$877.07 |
| D0220 |
Intraoral - periapical first radiographic image |
55 |
53 |
$467.86 |
| D1999 |
|
15 |
12 |
$0.00 |