| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
374 |
365 |
$13K |
| D0274 |
Bitewings - four radiographic images |
309 |
302 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
907 |
389 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
265 |
250 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
361 |
340 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
162 |
158 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
38 |
13 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
20 |
12 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
63 |
57 |
$949.77 |
| D1120 |
Prophylaxis - child |
28 |
24 |
$492.12 |