| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
852 |
850 |
$33K |
| D0120 |
Periodic oral evaluation - established patient |
963 |
963 |
$21K |
| D0274 |
Bitewings - four radiographic images |
654 |
654 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
882 |
877 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
86 |
37 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
753 |
752 |
$2K |
| D1206 |
Topical application of fluoride varnish |
81 |
81 |
$2K |
| D1120 |
Prophylaxis - child |
77 |
77 |
$315.00 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
19 |
13 |
$255.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
74 |
74 |
$225.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
78 |
78 |
$175.00 |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$80.00 |
| D0210 |
Intraoral - complete series of radiographic images |
15 |
15 |
$0.00 |