| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
487 |
487 |
$43K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
376 |
376 |
$25K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
216 |
58 |
$17K |
| D2332 |
|
186 |
49 |
$17K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
220 |
73 |
$15K |
| D0210 |
Intraoral - complete series of radiographic images |
282 |
282 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
220 |
53 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
768 |
761 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
73 |
73 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
735 |
245 |
$3K |
| D4910 |
|
13 |
13 |
$1K |
| D0274 |
Bitewings - four radiographic images |
45 |
45 |
$950.40 |
| D1120 |
Prophylaxis - child |
17 |
17 |
$892.50 |
| D9430 |
|
13 |
12 |
$416.00 |
| D1330 |
|
22 |
22 |
$0.00 |