| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
506 |
505 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
444 |
444 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
175 |
174 |
$6K |
| D0274 |
Bitewings - four radiographic images |
245 |
245 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
85 |
29 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
172 |
171 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
495 |
493 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
425 |
410 |
$2K |
| D1120 |
Prophylaxis - child |
34 |
34 |
$935.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
64 |
64 |
$682.00 |