| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,145 |
1,145 |
$49K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
623 |
396 |
$39K |
| D0120 |
Periodic oral evaluation - established patient |
1,096 |
1,096 |
$24K |
| D0274 |
Bitewings - four radiographic images |
645 |
645 |
$14K |
| D0210 |
Intraoral - complete series of radiographic images |
472 |
471 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
1,172 |
1,161 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,016 |
1,015 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
96 |
63 |
$4K |
| D1120 |
Prophylaxis - child |
52 |
52 |
$2K |
| D4341 |
|
34 |
12 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
45 |
45 |
$490.50 |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$269.28 |
| D0350 |
|
23 |
23 |
$240.81 |