| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,657 |
1,657 |
$143K |
| D0120 |
Periodic oral evaluation - established patient |
1,844 |
1,844 |
$106K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
826 |
826 |
$52K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
639 |
374 |
$42K |
| D0274 |
Bitewings - four radiographic images |
1,594 |
1,593 |
$34K |
| D0210 |
Intraoral - complete series of radiographic images |
711 |
711 |
$33K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,569 |
2,569 |
$33K |
| D1120 |
Prophylaxis - child |
606 |
606 |
$20K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,692 |
2,218 |
$17K |
| D9430 |
|
75 |
74 |
$2K |
| D0350 |
|
154 |
102 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
14 |
12 |
$1K |
| D1999 |
|
12 |
12 |
$46.00 |
| D4921 |
|
41 |
41 |
$0.00 |