| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
788 |
739 |
$35K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
351 |
235 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
909 |
853 |
$20K |
| D2335 |
|
97 |
51 |
$15K |
| D0210 |
Intraoral - complete series of radiographic images |
109 |
101 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
251 |
243 |
$5K |
| D2394 |
|
16 |
12 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
57 |
51 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
16 |
13 |
$1K |
| D0274 |
Bitewings - four radiographic images |
14 |
14 |
$520.90 |
| D3120 |
|
1,135 |
561 |
$0.00 |