| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
168 |
168 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
69 |
33 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
173 |
173 |
$4K |
| D0274 |
Bitewings - four radiographic images |
110 |
109 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
267 |
249 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
97 |
97 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
283 |
277 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
72 |
71 |
$2K |
| D1120 |
Prophylaxis - child |
55 |
55 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
23 |
13 |
$1K |
| D1351 |
Sealant - per tooth |
36 |
12 |
$594.62 |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$524.30 |