| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
875 |
872 |
$75K |
| D0120 |
Periodic oral evaluation - established patient |
543 |
542 |
$41K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
547 |
547 |
$36K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
666 |
342 |
$36K |
| D0210 |
Intraoral - complete series of radiographic images |
451 |
451 |
$22K |
| D2330 |
|
262 |
160 |
$21K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,248 |
1,247 |
$17K |
| D0274 |
Bitewings - four radiographic images |
491 |
490 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,370 |
906 |
$10K |
| D9430 |
|
275 |
260 |
$9K |
| D0350 |
|
151 |
44 |
$1K |
| D1120 |
Prophylaxis - child |
38 |
38 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
13 |
12 |
$873.60 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$144.00 |