| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
358 |
355 |
$29K |
| D0120 |
Periodic oral evaluation - established patient |
413 |
413 |
$25K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
371 |
146 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
194 |
193 |
$10K |
| D0350 |
|
845 |
384 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
152 |
151 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,434 |
322 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
83 |
43 |
$5K |
| D9430 |
|
151 |
148 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
202 |
200 |
$3K |
| D1120 |
Prophylaxis - child |
36 |
36 |
$1K |
| D4910 |
|
15 |
15 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
27 |
25 |
$324.00 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$259.20 |