| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
726 |
726 |
$42K |
| D0120 |
Periodic oral evaluation - established patient |
880 |
878 |
$25K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
199 |
183 |
$23K |
| D1120 |
Prophylaxis - child |
525 |
523 |
$22K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
126 |
114 |
$17K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
151 |
141 |
$15K |
| D0274 |
Bitewings - four radiographic images |
417 |
417 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
486 |
484 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
155 |
155 |
$5K |
| D1206 |
Topical application of fluoride varnish |
99 |
99 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
195 |
193 |
$3K |
| D0330 |
Panoramic radiographic image |
59 |
59 |
$2K |
| D0272 |
Bitewings - two radiographic images |
53 |
53 |
$901.00 |