| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
144 |
129 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
128 |
117 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
102 |
93 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
39 |
27 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
46 |
27 |
$880.00 |
| D0274 |
Bitewings - four radiographic images |
90 |
80 |
$360.00 |
| D0220 |
Intraoral - periapical first radiographic image |
136 |
124 |
$273.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
221 |
93 |
$258.00 |
| D0210 |
Intraoral - complete series of radiographic images |
40 |
33 |
$225.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
59 |
52 |
$75.00 |