| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,219 |
891 |
$57K |
| D0120 |
Periodic oral evaluation - established patient |
1,168 |
855 |
$27K |
| D0274 |
Bitewings - four radiographic images |
366 |
259 |
$12K |
| D1206 |
Topical application of fluoride varnish |
443 |
307 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
77 |
32 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
87 |
64 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
40 |
30 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
99 |
65 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
48 |
37 |
$558.00 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$310.50 |