| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
685 |
684 |
$34K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
269 |
173 |
$32K |
| D0120 |
Periodic oral evaluation - established patient |
1,019 |
1,019 |
$25K |
| D1120 |
Prophylaxis - child |
680 |
680 |
$23K |
| D1206 |
Topical application of fluoride varnish |
951 |
950 |
$19K |
| D0274 |
Bitewings - four radiographic images |
498 |
498 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
128 |
128 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
124 |
122 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
17 |
14 |
$2K |
| D0330 |
Panoramic radiographic image |
28 |
28 |
$2K |