| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
667 |
657 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
788 |
778 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
63 |
24 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
256 |
255 |
$4K |
| D9630 |
|
231 |
230 |
$4K |
| D0274 |
Bitewings - four radiographic images |
150 |
149 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
59 |
55 |
$2K |
| D1120 |
Prophylaxis - child |
25 |
25 |
$536.32 |
| D0220 |
Intraoral - periapical first radiographic image |
116 |
110 |
$217.95 |
| D0230 |
Intraoral - periapical each additional radiographic image |
51 |
44 |
$0.00 |