| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
445 |
441 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
264 |
186 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
716 |
716 |
$13K |
| D0274 |
Bitewings - four radiographic images |
243 |
242 |
$5K |
| D1206 |
Topical application of fluoride varnish |
285 |
284 |
$5K |
| D1120 |
Prophylaxis - child |
214 |
212 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
142 |
141 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
153 |
149 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
36 |
28 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
45 |
36 |
$2K |
| D2394 |
|
16 |
13 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
124 |
117 |
$609.50 |