| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
485 |
464 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
504 |
488 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
1,047 |
976 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
981 |
406 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
65 |
27 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
42 |
24 |
$4K |
| D0274 |
Bitewings - four radiographic images |
121 |
119 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
112 |
106 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
56 |
56 |
$1K |
| D1120 |
Prophylaxis - child |
28 |
28 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
29 |
29 |
$976.94 |