| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
224 |
218 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
241 |
237 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
74 |
39 |
$5K |
| D9110 |
|
93 |
85 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
188 |
170 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
47 |
16 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
71 |
70 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
172 |
96 |
$2K |
| D0274 |
Bitewings - four radiographic images |
59 |
56 |
$2K |
| D1120 |
Prophylaxis - child |
26 |
26 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
12 |
$375.00 |