| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,072 |
1,071 |
$49K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
398 |
271 |
$33K |
| D0120 |
Periodic oral evaluation - established patient |
1,004 |
1,004 |
$25K |
| D0330 |
Panoramic radiographic image |
448 |
448 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
390 |
390 |
$11K |
| D0274 |
Bitewings - four radiographic images |
177 |
177 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
52 |
43 |
$4K |
| D2394 |
|
25 |
16 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
13 |
$54.90 |