| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
774 |
689 |
$27K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
378 |
211 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
1,038 |
950 |
$19K |
| D1120 |
Prophylaxis - child |
221 |
204 |
$8K |
| D0274 |
Bitewings - four radiographic images |
303 |
282 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
417 |
387 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
40 |
25 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
32 |
27 |
$592.90 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
13 |
12 |
$585.42 |
| D0431 |
|
16 |
15 |
$90.00 |
| D0220 |
Intraoral - periapical first radiographic image |
16 |
12 |
$75.36 |
| D1999 |
|
19 |
16 |
$0.00 |