| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
899 |
897 |
$39K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
173 |
94 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
946 |
945 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
448 |
446 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
1,252 |
1,237 |
$16K |
| D0274 |
Bitewings - four radiographic images |
516 |
516 |
$16K |
| D0140 |
Limited oral evaluation - problem focused |
437 |
432 |
$15K |
| D0210 |
Intraoral - complete series of radiographic images |
207 |
206 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
609 |
608 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
39 |
24 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
24 |
15 |
$4K |
| D4910 |
|
25 |
25 |
$2K |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$205.56 |