| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
404 |
391 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
189 |
97 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
456 |
441 |
$8K |
| D0274 |
Bitewings - four radiographic images |
276 |
275 |
$6K |
| D1120 |
Prophylaxis - child |
111 |
111 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
104 |
104 |
$3K |
| D1206 |
Topical application of fluoride varnish |
166 |
165 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
96 |
92 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
264 |
242 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
264 |
135 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
42 |
41 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
16 |
12 |
$903.81 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
14 |
13 |
$746.33 |
| D0330 |
Panoramic radiographic image |
46 |
46 |
$594.96 |