| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
187 |
185 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
231 |
118 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
172 |
172 |
$6K |
| D4910 |
|
52 |
52 |
$4K |
| D4341 |
|
49 |
13 |
$3K |
| D2330 |
|
28 |
15 |
$2K |
| D7510 |
|
28 |
27 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
323 |
110 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
106 |
105 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
18 |
18 |
$680.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
14 |
14 |
$490.00 |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$280.80 |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$86.00 |