| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
438 |
434 |
$36K |
| D4910 |
|
382 |
376 |
$29K |
| D0120 |
Periodic oral evaluation - established patient |
348 |
347 |
$16K |
| D1208 |
Topical application of fluoride, excluding varnish |
607 |
602 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
41 |
24 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
26 |
26 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
17 |
14 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$576.00 |
| D0272 |
Bitewings - two radiographic images |
43 |
43 |
$478.00 |
| D0220 |
Intraoral - periapical first radiographic image |
38 |
38 |
$456.00 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$360.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
26 |
13 |
$125.55 |