| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
717 |
589 |
$22K |
| D0120 |
Periodic oral evaluation - established patient |
850 |
696 |
$18K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
144 |
65 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,096 |
583 |
$11K |
| D0274 |
Bitewings - four radiographic images |
495 |
401 |
$10K |
| D0330 |
Panoramic radiographic image |
331 |
243 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
779 |
641 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
585 |
486 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
273 |
192 |
$8K |
| D1120 |
Prophylaxis - child |
118 |
89 |
$2K |