| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
913 |
911 |
$45K |
| D1110 |
Prophylaxis - adult |
514 |
511 |
$43K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
638 |
329 |
$42K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,249 |
1,510 |
$30K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
228 |
228 |
$14K |
| D0274 |
Bitewings - four radiographic images |
545 |
543 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
187 |
118 |
$10K |
| D1120 |
Prophylaxis - child |
233 |
233 |
$7K |
| D9430 |
|
142 |
120 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
181 |
178 |
$2K |
| D2331 |
|
27 |
12 |
$2K |
| D2330 |
|
22 |
12 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
27 |
27 |
$256.00 |