| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
782 |
779 |
$32K |
| D0120 |
Periodic oral evaluation - established patient |
513 |
511 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
66 |
29 |
$7K |
| D0180 |
|
114 |
114 |
$5K |
| D0274 |
Bitewings - four radiographic images |
158 |
158 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
86 |
86 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
65 |
65 |
$797.17 |
| D0220 |
Intraoral - periapical first radiographic image |
65 |
65 |
$797.17 |
| D1206 |
Topical application of fluoride varnish |
37 |
37 |
$606.55 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$468.36 |