| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
741 |
741 |
$33K |
| D1206 |
Topical application of fluoride varnish |
765 |
765 |
$24K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
229 |
140 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
506 |
506 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
327 |
327 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
143 |
143 |
$6K |
| D1120 |
Prophylaxis - child |
115 |
115 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
538 |
535 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
362 |
362 |
$2K |
| D0274 |
Bitewings - four radiographic images |
149 |
149 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
16 |
13 |
$880.00 |
| D0603 |
|
41 |
41 |
$410.00 |
| D0272 |
Bitewings - two radiographic images |
24 |
24 |
$240.00 |