| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
354 |
354 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
238 |
237 |
$7K |
| D0274 |
Bitewings - four radiographic images |
156 |
155 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
38 |
28 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
97 |
97 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
14 |
12 |
$2K |
| D0330 |
Panoramic radiographic image |
24 |
24 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
70 |
69 |
$999.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
57 |
57 |
$969.50 |