| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
346 |
346 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
144 |
89 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
468 |
466 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
390 |
390 |
$8K |
| D0274 |
Bitewings - four radiographic images |
383 |
383 |
$8K |
| D4341 |
|
191 |
63 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
138 |
74 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
29 |
26 |
$2K |
| D1120 |
Prophylaxis - child |
67 |
67 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
145 |
145 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
39 |
39 |
$826.50 |
| D0272 |
Bitewings - two radiographic images |
22 |
22 |
$280.50 |