| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
545 |
497 |
$28K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
413 |
361 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
521 |
479 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
154 |
58 |
$12K |
| D1206 |
Topical application of fluoride varnish |
447 |
409 |
$10K |
| D0274 |
Bitewings - four radiographic images |
231 |
206 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
83 |
69 |
$5K |
| D1120 |
Prophylaxis - child |
129 |
118 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
70 |
36 |
$4K |
| D2394 |
|
23 |
13 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
36 |
25 |
$657.92 |
| D0220 |
Intraoral - periapical first radiographic image |
39 |
27 |
$259.82 |