| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,078 |
1,075 |
$21K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
299 |
85 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
627 |
626 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
331 |
331 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
221 |
221 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
1,093 |
1,074 |
$4K |
| D0274 |
Bitewings - four radiographic images |
458 |
458 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
695 |
692 |
$2K |
| D1120 |
Prophylaxis - child |
57 |
57 |
$1K |
| D1206 |
Topical application of fluoride varnish |
31 |
31 |
$232.50 |
| D1208 |
Topical application of fluoride, excluding varnish |
28 |
28 |
$168.00 |