| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,492 |
1,492 |
$71K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
591 |
349 |
$53K |
| D0120 |
Periodic oral evaluation - established patient |
2,087 |
2,087 |
$46K |
| D0274 |
Bitewings - four radiographic images |
1,226 |
1,224 |
$30K |
| D1120 |
Prophylaxis - child |
821 |
821 |
$28K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,641 |
1,641 |
$27K |
| D0220 |
Intraoral - periapical first radiographic image |
1,796 |
1,776 |
$21K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
171 |
99 |
$19K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,358 |
1,305 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
312 |
312 |
$12K |
| D0330 |
Panoramic radiographic image |
232 |
231 |
$10K |
| D1206 |
Topical application of fluoride varnish |
305 |
305 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
14 |
12 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
26 |
26 |
$883.20 |