| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
697 |
695 |
$31K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
388 |
213 |
$27K |
| D0120 |
Periodic oral evaluation - established patient |
850 |
846 |
$23K |
| D1206 |
Topical application of fluoride varnish |
976 |
972 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
291 |
291 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
803 |
778 |
$10K |
| D0274 |
Bitewings - four radiographic images |
370 |
367 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
247 |
238 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
94 |
72 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
166 |
166 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
786 |
642 |
$7K |
| D1120 |
Prophylaxis - child |
123 |
123 |
$5K |
| D4910 |
|
69 |
68 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
35 |
27 |
$2K |
| D1330 |
|
68 |
68 |
$180.00 |