| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,120 |
1,120 |
$39K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
179 |
173 |
$24K |
| D0210 |
Intraoral - complete series of radiographic images |
883 |
883 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
669 |
669 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
800 |
800 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
489 |
489 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
113 |
102 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
801 |
801 |
$8K |
| D0274 |
Bitewings - four radiographic images |
186 |
186 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
128 |
128 |
$1K |
| D1120 |
Prophylaxis - child |
13 |
13 |
$426.27 |