| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
604 |
604 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
591 |
591 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
1,039 |
1,033 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
916 |
914 |
$9K |
| D0274 |
Bitewings - four radiographic images |
356 |
356 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
148 |
148 |
$2K |
| D1120 |
Prophylaxis - child |
52 |
52 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
15 |
14 |
$778.18 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
12 |
12 |
$610.92 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
30 |
30 |
$607.84 |