| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,429 |
1,428 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
1,654 |
1,645 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
256 |
255 |
$1K |
| D1120 |
Prophylaxis - child |
243 |
243 |
$640.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
1,451 |
1,440 |
$588.00 |
| D0274 |
Bitewings - four radiographic images |
371 |
369 |
$550.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
211 |
210 |
$455.00 |
| D0220 |
Intraoral - periapical first radiographic image |
106 |
103 |
$75.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
20 |
12 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
121 |
76 |
$0.00 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
14 |
12 |
$0.00 |