| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
967 |
960 |
$25K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
705 |
305 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
1,221 |
1,211 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
867 |
858 |
$10K |
| D0274 |
Bitewings - four radiographic images |
600 |
593 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
532 |
231 |
$6K |
| D1120 |
Prophylaxis - child |
274 |
268 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
73 |
41 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
196 |
179 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
154 |
154 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
217 |
212 |
$2K |
| D0330 |
Panoramic radiographic image |
24 |
24 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
230 |
201 |
$464.96 |