| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
202 |
202 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
378 |
377 |
$647.60 |
| D0274 |
Bitewings - four radiographic images |
215 |
215 |
$642.70 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
112 |
84 |
$639.00 |
| D1206 |
Topical application of fluoride varnish |
414 |
412 |
$570.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
63 |
63 |
$532.00 |
| D0210 |
Intraoral - complete series of radiographic images |
24 |
24 |
$406.00 |
| D4910 |
|
153 |
153 |
$350.00 |
| D1120 |
Prophylaxis - child |
144 |
144 |
$238.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
121 |
97 |
$224.00 |
| D0220 |
Intraoral - periapical first radiographic image |
79 |
78 |
$156.00 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
14 |
$70.00 |
| D1310 |
|
60 |
60 |
$0.00 |
| D1354 |
|
74 |
41 |
$0.00 |