| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
608 |
530 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
410 |
387 |
$9K |
| D0330 |
Panoramic radiographic image |
295 |
261 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
272 |
135 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
441 |
402 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
171 |
87 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
364 |
331 |
$2K |
| D1120 |
Prophylaxis - child |
95 |
88 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
761 |
728 |
$604.16 |
| D0274 |
Bitewings - four radiographic images |
564 |
523 |
$455.62 |
| D0220 |
Intraoral - periapical first radiographic image |
510 |
470 |
$95.44 |
| D1330 |
|
797 |
762 |
$41.00 |