| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,400 |
1,346 |
$70K |
| D0274 |
Bitewings - four radiographic images |
723 |
696 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
767 |
735 |
$17K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
145 |
103 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
160 |
102 |
$10K |
| D1120 |
Prophylaxis - child |
93 |
91 |
$4K |
| D1206 |
Topical application of fluoride varnish |
112 |
107 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
70 |
65 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
52 |
51 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$670.00 |