| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
112 |
112 |
$5K |
| D0274 |
Bitewings - four radiographic images |
160 |
159 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
157 |
157 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
259 |
254 |
$4K |
| D1120 |
Prophylaxis - child |
77 |
77 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
36 |
18 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
22 |
15 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
95 |
95 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
286 |
218 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
47 |
47 |
$2K |