| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
630 |
629 |
$42K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
245 |
144 |
$33K |
| D0120 |
Periodic oral evaluation - established patient |
661 |
661 |
$21K |
| D1206 |
Topical application of fluoride varnish |
659 |
658 |
$17K |
| D0274 |
Bitewings - four radiographic images |
435 |
433 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
58 |
37 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
186 |
177 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
678 |
672 |
$8K |
| D0330 |
Panoramic radiographic image |
138 |
138 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
86 |
85 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
627 |
623 |
$4K |
| D1120 |
Prophylaxis - child |
66 |
66 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
15 |
13 |
$2K |
| D1330 |
|
103 |
103 |
$741.60 |
| D3120 |
|
21 |
12 |
$735.00 |