| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
536 |
533 |
$26K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
164 |
107 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
386 |
385 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
540 |
539 |
$15K |
| D1206 |
Topical application of fluoride varnish |
662 |
661 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
734 |
706 |
$12K |
| D1120 |
Prophylaxis - child |
286 |
286 |
$12K |
| D0274 |
Bitewings - four radiographic images |
283 |
283 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
469 |
361 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
107 |
106 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
38 |
38 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
18 |
15 |
$2K |