| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
207 |
108 |
$28K |
| D1110 |
Prophylaxis - adult |
501 |
461 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
1,016 |
952 |
$22K |
| D0274 |
Bitewings - four radiographic images |
383 |
350 |
$12K |
| D0140 |
Limited oral evaluation - problem focused |
237 |
219 |
$8K |
| D1120 |
Prophylaxis - child |
189 |
185 |
$6K |
| D1206 |
Topical application of fluoride varnish |
203 |
199 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
114 |
97 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
84 |
80 |
$1K |