| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
211 |
211 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
212 |
46 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
290 |
268 |
$6K |
| D1120 |
Prophylaxis - child |
137 |
115 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
93 |
93 |
$4K |
| D0274 |
Bitewings - four radiographic images |
97 |
91 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
67 |
54 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
82 |
68 |
$744.32 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
34 |
34 |
$725.28 |
| D0230 |
Intraoral - periapical each additional radiographic image |
75 |
63 |
$545.48 |