| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
640 |
640 |
$22K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
377 |
249 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
648 |
640 |
$11K |
| D0274 |
Bitewings - four radiographic images |
328 |
328 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
220 |
220 |
$6K |
| D1206 |
Topical application of fluoride varnish |
260 |
260 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
76 |
58 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
51 |
40 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
552 |
539 |
$3K |
| D1120 |
Prophylaxis - child |
117 |
117 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
90 |
89 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
392 |
247 |
$2K |
| D0330 |
Panoramic radiographic image |
36 |
36 |
$2K |