| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
847 |
846 |
$30K |
| D0120 |
Periodic oral evaluation - established patient |
698 |
698 |
$14K |
| D0274 |
Bitewings - four radiographic images |
347 |
346 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
85 |
85 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
120 |
120 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
35 |
28 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
208 |
207 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
31 |
26 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
44 |
44 |
$823.68 |
| D9110 |
|
17 |
17 |
$510.00 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$360.00 |