| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
762 |
751 |
$28K |
| D0120 |
Periodic oral evaluation - established patient |
504 |
496 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
22 |
13 |
$2K |
| D0274 |
Bitewings - four radiographic images |
91 |
90 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
51 |
43 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
38 |
37 |
$844.11 |
| D0220 |
Intraoral - periapical first radiographic image |
28 |
26 |
$313.04 |
| D9630 |
|
12 |
12 |
$309.96 |
| D9994 |
|
47 |
47 |
$0.00 |