| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,729 |
1,728 |
$131K |
| D0120 |
Periodic oral evaluation - established patient |
1,202 |
1,202 |
$46K |
| D0274 |
Bitewings - four radiographic images |
793 |
793 |
$33K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
281 |
169 |
$31K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
384 |
235 |
$28K |
| D0330 |
Panoramic radiographic image |
307 |
307 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
282 |
282 |
$10K |
| D1206 |
Topical application of fluoride varnish |
63 |
63 |
$2K |