| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
361 |
242 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
195 |
96 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
368 |
231 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
197 |
131 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
364 |
275 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
54 |
36 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
87 |
67 |
$2K |
| D1120 |
Prophylaxis - child |
24 |
13 |
$543.72 |
| D0140 |
Limited oral evaluation - problem focused |
16 |
14 |
$533.20 |
| D0274 |
Bitewings - four radiographic images |
24 |
12 |
$416.42 |
| D0220 |
Intraoral - periapical first radiographic image |
15 |
13 |
$143.14 |