| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
806 |
806 |
$31K |
| D0120 |
Periodic oral evaluation - established patient |
906 |
906 |
$18K |
| D0274 |
Bitewings - four radiographic images |
546 |
546 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
653 |
653 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
60 |
27 |
$3K |
| D4341 |
|
57 |
28 |
$2K |
| D2394 |
|
20 |
14 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
30 |
17 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
17 |
12 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
16 |
16 |
$702.50 |
| D1120 |
Prophylaxis - child |
13 |
13 |
$364.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
17 |
17 |
$158.27 |