| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,081 |
2,079 |
$90K |
| D0120 |
Periodic oral evaluation - established patient |
2,146 |
2,144 |
$49K |
| D0274 |
Bitewings - four radiographic images |
1,719 |
1,719 |
$39K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
499 |
350 |
$22K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
196 |
134 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
524 |
524 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
222 |
222 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
223 |
223 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
121 |
120 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
57 |
57 |
$740.20 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
14 |
13 |
$514.85 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$447.20 |