| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
331 |
316 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
249 |
237 |
$6K |
| D0274 |
Bitewings - four radiographic images |
315 |
303 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
518 |
484 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
525 |
368 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
127 |
126 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
35 |
13 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
70 |
63 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
18 |
12 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$205.99 |