| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
639 |
637 |
$20K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
265 |
108 |
$17K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,250 |
1,242 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
435 |
434 |
$7K |
| D0274 |
Bitewings - four radiographic images |
848 |
846 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
1,343 |
1,329 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
300 |
299 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
105 |
54 |
$4K |
| D1120 |
Prophylaxis - child |
114 |
113 |
$3K |
| D1206 |
Topical application of fluoride varnish |
109 |
109 |
$2K |
| D9920 |
|
31 |
31 |
$775.00 |
| D0602 |
|
13 |
13 |
$130.00 |
| D1330 |
|
15 |
15 |
$0.00 |