| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,196 |
1,194 |
$53K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
522 |
328 |
$35K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
589 |
278 |
$32K |
| D0120 |
Periodic oral evaluation - established patient |
960 |
959 |
$23K |
| D1208 |
Topical application of fluoride, excluding varnish |
739 |
738 |
$18K |
| D0210 |
Intraoral - complete series of radiographic images |
378 |
378 |
$17K |
| D1206 |
Topical application of fluoride varnish |
427 |
424 |
$10K |
| D0274 |
Bitewings - four radiographic images |
754 |
752 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
276 |
275 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
118 |
117 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
843 |
837 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
964 |
959 |
$4K |
| D2950 |
|
16 |
12 |
$715.00 |