| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
732 |
726 |
$32K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
372 |
216 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
520 |
519 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
510 |
506 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
189 |
120 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
279 |
276 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
151 |
151 |
$7K |
| D1206 |
Topical application of fluoride varnish |
251 |
250 |
$6K |
| D0274 |
Bitewings - four radiographic images |
456 |
452 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
585 |
574 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
639 |
634 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
42 |
42 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
17 |
17 |
$1K |
| D0603 |
|
103 |
102 |
$460.00 |