| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
512 |
510 |
$39K |
| D0120 |
Periodic oral evaluation - established patient |
732 |
722 |
$33K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,019 |
516 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
66 |
66 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
62 |
41 |
$3K |
| D0272 |
Bitewings - two radiographic images |
316 |
313 |
$3K |
| D4341 |
|
46 |
12 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
29 |
16 |
$2K |
| D2330 |
|
27 |
12 |
$2K |
| D1206 |
Topical application of fluoride varnish |
42 |
42 |
$685.50 |
| D2920 |
|
15 |
12 |
$546.00 |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$520.00 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$275.00 |
| D1120 |
Prophylaxis - child |
13 |
13 |
$225.00 |