| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
825 |
720 |
$37K |
| D0120 |
Periodic oral evaluation - established patient |
920 |
812 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
358 |
290 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
162 |
129 |
$8K |
| D0274 |
Bitewings - four radiographic images |
223 |
184 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
26 |
12 |
$3K |
| D1206 |
Topical application of fluoride varnish |
95 |
84 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
107 |
77 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
71 |
59 |
$759.30 |