| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
193 |
184 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
270 |
263 |
$6K |
| D0330 |
Panoramic radiographic image |
97 |
95 |
$3K |
| D0274 |
Bitewings - four radiographic images |
132 |
123 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
46 |
29 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
138 |
130 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
17 |
12 |
$745.10 |
| D0220 |
Intraoral - periapical first radiographic image |
90 |
84 |
$535.99 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
15 |
14 |
$327.60 |