| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
357 |
357 |
$24K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
319 |
318 |
$18K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
93 |
50 |
$13K |
| D0210 |
Intraoral - complete series of radiographic images |
206 |
204 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
321 |
320 |
$8K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
41 |
25 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
130 |
129 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
16 |
13 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
51 |
51 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
39 |
38 |
$460.98 |
| D1206 |
Topical application of fluoride varnish |
15 |
15 |
$394.35 |