| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,350 |
1,343 |
$47K |
| D0120 |
Periodic oral evaluation - established patient |
1,480 |
1,472 |
$29K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
387 |
313 |
$23K |
| D0274 |
Bitewings - four radiographic images |
513 |
508 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
530 |
529 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
142 |
114 |
$7K |
| D1120 |
Prophylaxis - child |
221 |
221 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
199 |
197 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
95 |
95 |
$727.35 |
| D0272 |
Bitewings - two radiographic images |
41 |
40 |
$652.70 |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$540.00 |