| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
835 |
835 |
$38K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
278 |
244 |
$36K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
189 |
171 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
658 |
658 |
$15K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
84 |
74 |
$14K |
| D0210 |
Intraoral - complete series of radiographic images |
371 |
367 |
$13K |
| D0274 |
Bitewings - four radiographic images |
493 |
493 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
387 |
387 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
756 |
746 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
598 |
598 |
$6K |
| D9310 |
|
90 |
90 |
$5K |
| D1120 |
Prophylaxis - child |
49 |
49 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
118 |
118 |
$1K |