| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,159 |
1,067 |
$59K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
293 |
152 |
$24K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
446 |
412 |
$17K |
| D0210 |
Intraoral - complete series of radiographic images |
208 |
192 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
613 |
584 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
199 |
96 |
$13K |
| D3120 |
|
358 |
133 |
$12K |
| D0274 |
Bitewings - four radiographic images |
243 |
229 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
553 |
515 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
261 |
239 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
37 |
24 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
86 |
81 |
$2K |
| D1120 |
Prophylaxis - child |
14 |
13 |
$663.00 |