| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,483 |
1,464 |
$63K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
757 |
251 |
$55K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,943 |
1,914 |
$41K |
| D0120 |
Periodic oral evaluation - established patient |
1,592 |
1,570 |
$39K |
| D0274 |
Bitewings - four radiographic images |
660 |
648 |
$17K |
| D1120 |
Prophylaxis - child |
470 |
461 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
348 |
339 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
31 |
15 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
21 |
12 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
128 |
121 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
54 |
53 |
$1K |
| D0272 |
Bitewings - two radiographic images |
74 |
73 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
19 |
14 |
$160.26 |