| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
640 |
592 |
$18K |
| D1120 |
Prophylaxis - child |
246 |
235 |
$10K |
| D0274 |
Bitewings - four radiographic images |
301 |
274 |
$6K |
| D1206 |
Topical application of fluoride varnish |
124 |
115 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
145 |
132 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
15 |
12 |
$604.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
15 |
13 |
$510.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$260.00 |
| D0220 |
Intraoral - periapical first radiographic image |
16 |
16 |
$146.00 |