| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
596 |
566 |
$21K |
| D0274 |
Bitewings - four radiographic images |
432 |
416 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
491 |
475 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
115 |
64 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
78 |
38 |
$5K |
| D1206 |
Topical application of fluoride varnish |
149 |
139 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
36 |
28 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
73 |
64 |
$959.80 |