| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
579 |
579 |
$31K |
| D0120 |
Periodic oral evaluation - established patient |
517 |
517 |
$14K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
94 |
58 |
$9K |
| D0274 |
Bitewings - four radiographic images |
349 |
349 |
$9K |
| D2394 |
|
45 |
35 |
$6K |
| D0330 |
Panoramic radiographic image |
101 |
101 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
36 |
30 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
70 |
70 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
25 |
25 |
$332.50 |
| D0220 |
Intraoral - periapical first radiographic image |
14 |
14 |
$137.35 |