| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
482 |
472 |
$20K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
206 |
108 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
546 |
524 |
$12K |
| D0274 |
Bitewings - four radiographic images |
392 |
386 |
$9K |
| D0330 |
Panoramic radiographic image |
227 |
222 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
228 |
225 |
$6K |
| D1206 |
Topical application of fluoride varnish |
323 |
306 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
89 |
60 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
187 |
186 |
$4K |
| D1120 |
Prophylaxis - child |
109 |
108 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
23 |
14 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
14 |
14 |
$317.20 |
| D0220 |
Intraoral - periapical first radiographic image |
14 |
14 |
$179.34 |