| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
984 |
978 |
$33K |
| D0274 |
Bitewings - four radiographic images |
511 |
507 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
702 |
698 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
134 |
88 |
$8K |
| D1206 |
Topical application of fluoride varnish |
384 |
384 |
$7K |
| D0330 |
Panoramic radiographic image |
171 |
171 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
109 |
53 |
$5K |
| D1330 |
|
318 |
314 |
$3K |
| D1310 |
|
321 |
317 |
$3K |
| D1120 |
Prophylaxis - child |
89 |
89 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
120 |
118 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
39 |
39 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
15 |
12 |
$913.90 |