| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,159 |
1,158 |
$62K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
243 |
231 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
840 |
840 |
$23K |
| D0210 |
Intraoral - complete series of radiographic images |
352 |
350 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
593 |
592 |
$18K |
| D0274 |
Bitewings - four radiographic images |
232 |
232 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
315 |
315 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
96 |
96 |
$1K |
| D1120 |
Prophylaxis - child |
26 |
26 |
$989.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
12 |
12 |
$982.30 |
| D0220 |
Intraoral - periapical first radiographic image |
25 |
25 |
$297.92 |
| D1999 |
|
749 |
656 |
$0.00 |