| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
93 |
90 |
$4K |
| D1206 |
Topical application of fluoride varnish |
92 |
92 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
25 |
16 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
31 |
15 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
63 |
62 |
$2K |
| D1120 |
Prophylaxis - child |
28 |
28 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
29 |
27 |
$652.50 |
| D0274 |
Bitewings - four radiographic images |
49 |
46 |
$537.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
78 |
75 |
$442.01 |
| D0220 |
Intraoral - periapical first radiographic image |
87 |
83 |
$411.10 |
| D0602 |
|
13 |
13 |
$130.00 |