| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
347 |
347 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
392 |
392 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
21 |
12 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
55 |
55 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
44 |
44 |
$2K |
| D1120 |
Prophylaxis - child |
31 |
31 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
244 |
238 |
$1K |
| D1206 |
Topical application of fluoride varnish |
32 |
32 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
17 |
14 |
$930.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
139 |
122 |
$556.00 |
| D0274 |
Bitewings - four radiographic images |
55 |
55 |
$540.00 |
| D0140 |
Limited oral evaluation - problem focused |
25 |
24 |
$283.00 |