| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
462 |
462 |
$20K |
| D1206 |
Topical application of fluoride varnish |
461 |
459 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
435 |
435 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
126 |
88 |
$8K |
| D0274 |
Bitewings - four radiographic images |
315 |
315 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
58 |
58 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
415 |
414 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
368 |
368 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
25 |
17 |
$1K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
15 |
15 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
14 |
14 |
$490.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$275.00 |