| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
245 |
244 |
$14K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
84 |
43 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
345 |
339 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
345 |
325 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
183 |
179 |
$5K |
| D0274 |
Bitewings - four radiographic images |
126 |
125 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
54 |
54 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
23 |
16 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
203 |
188 |
$2K |