| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
351 |
331 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
171 |
102 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
408 |
389 |
$8K |
| D1120 |
Prophylaxis - child |
165 |
161 |
$7K |
| D0274 |
Bitewings - four radiographic images |
209 |
198 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
234 |
225 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
60 |
41 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
47 |
29 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
60 |
54 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
49 |
44 |
$369.60 |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$177.00 |