| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,330 |
1,287 |
$50K |
| D0120 |
Periodic oral evaluation - established patient |
1,781 |
1,734 |
$35K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
99 |
51 |
$6K |
| D0274 |
Bitewings - four radiographic images |
152 |
151 |
$4K |
| D1120 |
Prophylaxis - child |
113 |
113 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
14 |
12 |
$667.72 |
| D0272 |
Bitewings - two radiographic images |
24 |
24 |
$452.01 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$347.18 |
| D0220 |
Intraoral - periapical first radiographic image |
14 |
12 |
$132.99 |