| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,090 |
1,088 |
$38K |
| D0120 |
Periodic oral evaluation - established patient |
911 |
910 |
$18K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
324 |
224 |
$16K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
216 |
152 |
$15K |
| D0274 |
Bitewings - four radiographic images |
772 |
772 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
972 |
971 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
899 |
896 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
146 |
146 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
170 |
170 |
$4K |
| D2335 |
|
24 |
15 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
26 |
20 |
$2K |
| D2330 |
|
14 |
12 |
$534.51 |
| D1208 |
Topical application of fluoride, excluding varnish |
42 |
42 |
$455.30 |