| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
767 |
767 |
$67K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
777 |
339 |
$52K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
719 |
719 |
$47K |
| D0210 |
Intraoral - complete series of radiographic images |
697 |
697 |
$33K |
| D0120 |
Periodic oral evaluation - established patient |
241 |
241 |
$19K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,151 |
1,149 |
$16K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
208 |
105 |
$11K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
136 |
80 |
$11K |
| D9430 |
|
281 |
275 |
$9K |
| D0274 |
Bitewings - four radiographic images |
221 |
221 |
$5K |
| D0350 |
|
454 |
222 |
$4K |
| D1120 |
Prophylaxis - child |
50 |
50 |
$2K |
| D9110 |
|
13 |
12 |
$63.00 |