| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
899 |
897 |
$44K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
209 |
98 |
$28K |
| D0120 |
Periodic oral evaluation - established patient |
564 |
562 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
108 |
49 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
199 |
199 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
424 |
419 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
51 |
50 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
255 |
255 |
$3K |
| D0274 |
Bitewings - four radiographic images |
98 |
98 |
$3K |
| D1206 |
Topical application of fluoride varnish |
42 |
41 |
$802.44 |