| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
460 |
450 |
$29K |
| D0120 |
Periodic oral evaluation - established patient |
403 |
401 |
$13K |
| D1206 |
Topical application of fluoride varnish |
356 |
347 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
145 |
138 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
69 |
65 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
31 |
12 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
23 |
12 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
79 |
79 |
$2K |
| D1120 |
Prophylaxis - child |
25 |
25 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
102 |
97 |
$1K |
| D0274 |
Bitewings - four radiographic images |
40 |
40 |
$962.80 |
| D1330 |
|
40 |
40 |
$240.00 |