| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
4,195 |
4,192 |
$220K |
| D0120 |
Periodic oral evaluation - established patient |
4,637 |
4,634 |
$124K |
| D0274 |
Bitewings - four radiographic images |
2,146 |
2,143 |
$77K |
| D1120 |
Prophylaxis - child |
1,268 |
1,268 |
$50K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
645 |
475 |
$49K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,161 |
2,161 |
$30K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
917 |
916 |
$26K |
| D0272 |
Bitewings - two radiographic images |
576 |
576 |
$12K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
56 |
51 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
51 |
36 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
54 |
51 |
$714.10 |