| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
263 |
251 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
75 |
43 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
107 |
102 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
52 |
49 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
82 |
81 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
17 |
12 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
56 |
56 |
$739.25 |
| D1206 |
Topical application of fluoride varnish |
18 |
16 |
$350.00 |