| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
961 |
951 |
$50K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
293 |
149 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
969 |
961 |
$23K |
| D0274 |
Bitewings - four radiographic images |
408 |
408 |
$15K |
| D1208 |
Topical application of fluoride, excluding varnish |
363 |
362 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
160 |
95 |
$10K |
| D1120 |
Prophylaxis - child |
92 |
92 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
220 |
215 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
35 |
35 |
$2K |
| D9110 |
|
39 |
38 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
14 |
$966.00 |