| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
199 |
197 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
82 |
82 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
177 |
174 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
105 |
102 |
$4K |
| D0274 |
Bitewings - four radiographic images |
127 |
126 |
$2K |
| D2950 |
|
14 |
12 |
$2K |
| D1120 |
Prophylaxis - child |
47 |
46 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
28 |
17 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
89 |
87 |
$872.96 |
| D1208 |
Topical application of fluoride, excluding varnish |
44 |
43 |
$730.14 |