| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
472 |
464 |
$16K |
| D0274 |
Bitewings - four radiographic images |
372 |
366 |
$10K |
| D0330 |
Panoramic radiographic image |
244 |
236 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
142 |
91 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
394 |
393 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
88 |
67 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
222 |
218 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
120 |
119 |
$2K |
| D1120 |
Prophylaxis - child |
39 |
39 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
141 |
136 |
$842.00 |
| D0272 |
Bitewings - two radiographic images |
17 |
17 |
$256.00 |