| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
642 |
641 |
$29K |
| D0120 |
Periodic oral evaluation - established patient |
626 |
626 |
$17K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
207 |
121 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
384 |
383 |
$14K |
| D0210 |
Intraoral - complete series of radiographic images |
180 |
180 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
580 |
568 |
$7K |
| D0274 |
Bitewings - four radiographic images |
170 |
170 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
128 |
126 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
359 |
319 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
35 |
25 |
$2K |
| D1206 |
Topical application of fluoride varnish |
80 |
80 |
$1K |
| D1999 |
|
162 |
130 |
$1K |
| D1120 |
Prophylaxis - child |
13 |
13 |
$520.00 |