| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
547 |
539 |
$21K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
110 |
49 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
472 |
463 |
$7K |
| D0274 |
Bitewings - four radiographic images |
173 |
172 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
36 |
13 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
189 |
183 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
260 |
242 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
41 |
41 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
56 |
42 |
$545.48 |
| D9920 |
|
12 |
12 |
$479.50 |
| D9630 |
|
31 |
31 |
$0.00 |
| D9994 |
|
114 |
114 |
$0.00 |