| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
165 |
163 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
59 |
42 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
144 |
142 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
44 |
35 |
$3K |
| D0274 |
Bitewings - four radiographic images |
83 |
83 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
29 |
29 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
49 |
49 |
$900.00 |
| D1120 |
Prophylaxis - child |
24 |
24 |
$690.00 |
| D1206 |
Topical application of fluoride varnish |
42 |
41 |
$684.00 |
| D9110 |
|
19 |
19 |
$570.00 |
| D0220 |
Intraoral - periapical first radiographic image |
50 |
49 |
$361.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
22 |
15 |
$128.00 |