| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
274 |
267 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
52 |
27 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
451 |
427 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
211 |
205 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
112 |
112 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
275 |
262 |
$4K |
| D0274 |
Bitewings - four radiographic images |
106 |
102 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
15 |
12 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
54 |
52 |
$2K |
| D1206 |
Topical application of fluoride varnish |
14 |
14 |
$229.60 |