| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,038 |
1,038 |
$45K |
| D0120 |
Periodic oral evaluation - established patient |
1,107 |
1,107 |
$24K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
321 |
217 |
$20K |
| D0210 |
Intraoral - complete series of radiographic images |
355 |
355 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
296 |
181 |
$12K |
| D0274 |
Bitewings - four radiographic images |
473 |
473 |
$10K |
| D1120 |
Prophylaxis - child |
257 |
257 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
562 |
562 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
530 |
530 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
218 |
218 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
314 |
314 |
$3K |
| D9110 |
|
100 |
100 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
18 |
12 |
$1K |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$165.36 |