| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,357 |
1,356 |
$92K |
| D1120 |
Prophylaxis - child |
648 |
646 |
$34K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
210 |
119 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
3,075 |
3,070 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
53 |
39 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,207 |
1,206 |
$1K |
| D0274 |
Bitewings - four radiographic images |
236 |
235 |
$762.05 |
| D1206 |
Topical application of fluoride varnish |
409 |
409 |
$366.13 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$330.09 |
| D0272 |
Bitewings - two radiographic images |
79 |
79 |
$166.80 |
| D0220 |
Intraoral - periapical first radiographic image |
167 |
165 |
$38.48 |
| D0230 |
Intraoral - periapical each additional radiographic image |
39 |
39 |
$0.00 |