| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
533 |
525 |
$23K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
563 |
554 |
$19K |
| D0210 |
Intraoral - complete series of radiographic images |
453 |
447 |
$19K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
239 |
124 |
$16K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
123 |
62 |
$9K |
| D1206 |
Topical application of fluoride varnish |
468 |
460 |
$8K |
| D2394 |
|
43 |
26 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
143 |
143 |
$4K |
| D0703 |
|
519 |
509 |
$4K |
| D0274 |
Bitewings - four radiographic images |
35 |
35 |
$957.00 |
| D0220 |
Intraoral - periapical first radiographic image |
39 |
38 |
$494.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
21 |
18 |
$189.00 |
| D1330 |
|
227 |
220 |
$110.00 |