| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
99 |
99 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
46 |
27 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
91 |
91 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
73 |
73 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
37 |
37 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
26 |
17 |
$1K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
16 |
12 |
$1K |
| D0274 |
Bitewings - four radiographic images |
62 |
62 |
$684.00 |
| D0140 |
Limited oral evaluation - problem focused |
17 |
17 |
$675.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
73 |
72 |
$432.00 |
| D0220 |
Intraoral - periapical first radiographic image |
85 |
85 |
$385.00 |
| D1206 |
Topical application of fluoride varnish |
13 |
13 |
$312.50 |