| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
922 |
919 |
$33K |
| D0120 |
Periodic oral evaluation - established patient |
694 |
690 |
$14K |
| D0274 |
Bitewings - four radiographic images |
691 |
691 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
179 |
99 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
1,040 |
1,030 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
778 |
769 |
$6K |
| D1120 |
Prophylaxis - child |
63 |
63 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
89 |
89 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
20 |
12 |
$760.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
13 |
$145.60 |