| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
447 |
443 |
$29K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
132 |
46 |
$23K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
278 |
275 |
$15K |
| D0210 |
Intraoral - complete series of radiographic images |
196 |
196 |
$11K |
| D2750 |
|
22 |
14 |
$11K |
| D1206 |
Topical application of fluoride varnish |
380 |
375 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
65 |
39 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
114 |
114 |
$4K |
| D2950 |
|
22 |
14 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
26 |
25 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
68 |
63 |
$801.28 |