| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
127 |
112 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
128 |
110 |
$2K |
| D0274 |
Bitewings - four radiographic images |
65 |
57 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
78 |
71 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
33 |
26 |
$993.01 |
| D9110 |
|
35 |
33 |
$937.20 |
| D1120 |
Prophylaxis - child |
58 |
50 |
$925.81 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
16 |
12 |
$755.82 |
| D0220 |
Intraoral - periapical first radiographic image |
87 |
83 |
$546.89 |
| D1330 |
|
55 |
46 |
$205.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
13 |
$102.65 |
| D0230 |
Intraoral - periapical each additional radiographic image |
32 |
23 |
$102.24 |