| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,648 |
1,647 |
$84K |
| D0120 |
Periodic oral evaluation - established patient |
1,019 |
1,019 |
$27K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
246 |
122 |
$25K |
| D2750 |
|
37 |
25 |
$20K |
| D0274 |
Bitewings - four radiographic images |
664 |
664 |
$18K |
| D1320 |
|
1,647 |
1,646 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
349 |
349 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
315 |
314 |
$9K |
| D2335 |
|
56 |
25 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
188 |
183 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
15 |
13 |
$1K |
| D2951 |
|
35 |
24 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
54 |
54 |
$756.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
65 |
65 |
$611.94 |
| D1999 |
|
16 |
15 |
$0.00 |