| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
603 |
594 |
$20K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
256 |
155 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
250 |
148 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
688 |
675 |
$13K |
| D0272 |
Bitewings - two radiographic images |
157 |
156 |
$2K |
| D2332 |
|
23 |
12 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$560.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
26 |
25 |
$436.62 |
| D0220 |
Intraoral - periapical first radiographic image |
43 |
43 |
$281.20 |