| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,309 |
1,306 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
1,349 |
1,345 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,058 |
1,056 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
175 |
106 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
252 |
252 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
1,345 |
1,334 |
$3K |
| D0274 |
Bitewings - four radiographic images |
403 |
403 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
248 |
248 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,399 |
1,129 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
59 |
17 |
$2K |
| D1120 |
Prophylaxis - child |
104 |
104 |
$1K |
| D1206 |
Topical application of fluoride varnish |
73 |
73 |
$593.75 |
| D0273 |
|
14 |
14 |
$99.60 |