| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
372 |
362 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
384 |
375 |
$7K |
| D0274 |
Bitewings - four radiographic images |
217 |
212 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
502 |
489 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
388 |
349 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
26 |
17 |
$1K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
16 |
12 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
56 |
53 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
28 |
25 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$491.80 |