| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
813 |
715 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
831 |
729 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
147 |
109 |
$3K |
| D2394 |
|
52 |
17 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
82 |
27 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
245 |
221 |
$1K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
31 |
13 |
$975.00 |
| D0274 |
Bitewings - four radiographic images |
52 |
46 |
$880.00 |
| D1206 |
Topical application of fluoride varnish |
68 |
57 |
$750.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
112 |
101 |
$505.00 |
| D1120 |
Prophylaxis - child |
14 |
14 |
$280.00 |