| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
193 |
184 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
286 |
274 |
$7K |
| D0274 |
Bitewings - four radiographic images |
184 |
173 |
$5K |
| D0350 |
|
209 |
197 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
246 |
233 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
28 |
16 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
21 |
14 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$635.76 |
| D1120 |
Prophylaxis - child |
15 |
15 |
$551.25 |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$280.56 |
| D0220 |
Intraoral - periapical first radiographic image |
14 |
12 |
$138.16 |
| D0230 |
Intraoral - periapical each additional radiographic image |
14 |
12 |
$115.10 |
| D0602 |
|
305 |
293 |
$0.00 |