| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
781 |
780 |
$63K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
745 |
236 |
$40K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
673 |
671 |
$40K |
| D0120 |
Periodic oral evaluation - established patient |
678 |
677 |
$33K |
| D0210 |
Intraoral - complete series of radiographic images |
531 |
530 |
$24K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,792 |
1,790 |
$22K |
| D1120 |
Prophylaxis - child |
441 |
441 |
$14K |
| D0274 |
Bitewings - four radiographic images |
606 |
606 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
181 |
92 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,981 |
1,143 |
$12K |
| D0350 |
|
109 |
42 |
$1K |
| D9110 |
|
13 |
13 |
$819.00 |
| D0220 |
Intraoral - periapical first radiographic image |
58 |
58 |
$696.00 |
| D9430 |
|
12 |
12 |
$384.00 |