| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
571 |
567 |
$50K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
554 |
551 |
$36K |
| D0210 |
Intraoral - complete series of radiographic images |
323 |
321 |
$15K |
| D1208 |
Topical application of fluoride, excluding varnish |
866 |
853 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
29 |
29 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
33 |
12 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
26 |
15 |
$2K |
| D0274 |
Bitewings - four radiographic images |
57 |
57 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
33 |
13 |
$125.55 |