| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
618 |
615 |
$22K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
330 |
200 |
$21K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
323 |
192 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
568 |
566 |
$11K |
| D0274 |
Bitewings - four radiographic images |
199 |
199 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
254 |
253 |
$5K |
| D1120 |
Prophylaxis - child |
136 |
136 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
51 |
40 |
$3K |
| D1206 |
Topical application of fluoride varnish |
177 |
177 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
72 |
70 |
$3K |
| D1330 |
|
216 |
215 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
31 |
31 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
88 |
87 |
$713.00 |