| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
515 |
511 |
$16K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
39 |
15 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
464 |
462 |
$6K |
| D2394 |
|
22 |
13 |
$4K |
| D0274 |
Bitewings - four radiographic images |
188 |
188 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
17 |
12 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
39 |
39 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
72 |
72 |
$831.60 |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$710.56 |
| D0220 |
Intraoral - periapical first radiographic image |
75 |
67 |
$639.32 |