| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
956 |
953 |
$31K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
155 |
131 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
792 |
790 |
$15K |
| D0210 |
Intraoral - complete series of radiographic images |
740 |
738 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
415 |
414 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
787 |
787 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
779 |
779 |
$7K |
| D0274 |
Bitewings - four radiographic images |
289 |
288 |
$5K |
| D1120 |
Prophylaxis - child |
91 |
90 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
29 |
26 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
98 |
97 |
$1K |
| D0330 |
Panoramic radiographic image |
23 |
23 |
$412.50 |