| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
843 |
825 |
$28K |
| D0120 |
Periodic oral evaluation - established patient |
1,467 |
1,443 |
$25K |
| D1120 |
Prophylaxis - child |
736 |
726 |
$15K |
| D0274 |
Bitewings - four radiographic images |
622 |
615 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
688 |
677 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
96 |
73 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
100 |
64 |
$5K |
| D0272 |
Bitewings - two radiographic images |
246 |
241 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
18 |
18 |
$474.30 |
| D0220 |
Intraoral - periapical first radiographic image |
91 |
83 |
$400.50 |