| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
725 |
712 |
$28K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
105 |
61 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
736 |
720 |
$12K |
| D0274 |
Bitewings - four radiographic images |
464 |
454 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
97 |
60 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
307 |
294 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
92 |
88 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
261 |
244 |
$2K |
| D1120 |
Prophylaxis - child |
36 |
36 |
$522.96 |