| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
364 |
363 |
$12K |
| D0274 |
Bitewings - four radiographic images |
390 |
388 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
98 |
49 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
527 |
523 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
197 |
196 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
60 |
32 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
172 |
172 |
$3K |
| D2332 |
|
57 |
27 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
429 |
426 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
30 |
15 |
$2K |
| D9110 |
|
13 |
13 |
$378.45 |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
13 |
$235.41 |