| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
254 |
242 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
168 |
90 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
136 |
135 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
231 |
223 |
$6K |
| D0330 |
Panoramic radiographic image |
143 |
138 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
155 |
153 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
42 |
27 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
60 |
27 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
102 |
99 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
215 |
204 |
$1K |
| D0274 |
Bitewings - four radiographic images |
62 |
57 |
$1K |
| D1120 |
Prophylaxis - child |
14 |
14 |
$610.87 |
| D1206 |
Topical application of fluoride varnish |
41 |
40 |
$529.50 |