| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,179 |
1,179 |
$58K |
| D0120 |
Periodic oral evaluation - established patient |
2,005 |
2,005 |
$52K |
| D1120 |
Prophylaxis - child |
1,214 |
1,214 |
$47K |
| D1206 |
Topical application of fluoride varnish |
1,483 |
1,483 |
$35K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
251 |
174 |
$28K |
| D0274 |
Bitewings - four radiographic images |
483 |
483 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
275 |
275 |
$12K |
| D2740 |
Crown - porcelain/ceramic |
16 |
14 |
$11K |
| D2335 |
|
38 |
24 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
71 |
71 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
32 |
27 |
$5K |
| D0272 |
Bitewings - two radiographic images |
150 |
150 |
$3K |
| D2950 |
|
16 |
13 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
25 |
25 |
$376.37 |