| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
306 |
304 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
353 |
350 |
$7K |
| D0272 |
Bitewings - two radiographic images |
266 |
265 |
$4K |
| D1120 |
Prophylaxis - child |
99 |
98 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
51 |
41 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
149 |
148 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
54 |
40 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
46 |
46 |
$900.00 |
| D0220 |
Intraoral - periapical first radiographic image |
62 |
60 |
$456.00 |