| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
687 |
584 |
$11K |
| D1110 |
Prophylaxis - adult |
260 |
233 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
26 |
14 |
$2K |
| D0274 |
Bitewings - four radiographic images |
64 |
39 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
29 |
12 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
143 |
121 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
15 |
12 |
$93.93 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
15 |
12 |
$81.65 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$0.00 |