| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,294 |
1,575 |
$67K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
613 |
303 |
$45K |
| D0120 |
Periodic oral evaluation - established patient |
1,428 |
1,071 |
$28K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
719 |
531 |
$21K |
| D0210 |
Intraoral - complete series of radiographic images |
804 |
547 |
$20K |
| D1120 |
Prophylaxis - child |
470 |
445 |
$15K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
129 |
82 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
611 |
554 |
$10K |
| D0274 |
Bitewings - four radiographic images |
422 |
256 |
$8K |
| D0272 |
Bitewings - two radiographic images |
259 |
225 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
89 |
47 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
368 |
247 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
126 |
89 |
$691.03 |