| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
475 |
475 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
677 |
676 |
$18K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
164 |
82 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
846 |
834 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
94 |
53 |
$11K |
| D0274 |
Bitewings - four radiographic images |
307 |
307 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
405 |
405 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
773 |
638 |
$7K |
| D1120 |
Prophylaxis - child |
174 |
174 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
164 |
163 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
13 |
12 |
$511.98 |