| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
709 |
709 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
655 |
655 |
$14K |
| D0274 |
Bitewings - four radiographic images |
277 |
277 |
$6K |
| D1120 |
Prophylaxis - child |
101 |
101 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
453 |
436 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
38 |
29 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
113 |
113 |
$3K |
| D0272 |
Bitewings - two radiographic images |
45 |
45 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
30 |
30 |
$994.35 |
| D0230 |
Intraoral - periapical each additional radiographic image |
226 |
132 |
$919.28 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
15 |
13 |
$908.64 |