| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
588 |
588 |
$49K |
| D0120 |
Periodic oral evaluation - established patient |
774 |
774 |
$39K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
350 |
162 |
$19K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,365 |
1,363 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
224 |
224 |
$14K |
| D1120 |
Prophylaxis - child |
275 |
275 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
149 |
149 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
33 |
27 |
$2K |
| D0274 |
Bitewings - four radiographic images |
89 |
88 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
339 |
83 |
$1K |