| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
958 |
862 |
$43K |
| D0274 |
Bitewings - four radiographic images |
1,085 |
959 |
$30K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
389 |
171 |
$26K |
| D0120 |
Periodic oral evaluation - established patient |
855 |
762 |
$20K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
128 |
68 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
856 |
784 |
$11K |
| D0350 |
|
640 |
551 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
291 |
252 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
294 |
214 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
63 |
51 |
$2K |
| D0603 |
|
827 |
768 |
$0.00 |
| D0602 |
|
66 |
58 |
$0.00 |
| D0601 |
|
13 |
13 |
$0.00 |