| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
857 |
857 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
546 |
546 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
612 |
612 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
225 |
225 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
327 |
327 |
$5K |
| D0274 |
Bitewings - four radiographic images |
328 |
328 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
83 |
52 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
655 |
645 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
552 |
532 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
22 |
12 |
$635.00 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
18 |
13 |
$610.00 |
| D1206 |
Topical application of fluoride varnish |
31 |
31 |
$604.50 |