| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
249 |
245 |
$9K |
| D0330 |
Panoramic radiographic image |
183 |
177 |
$7K |
| D0274 |
Bitewings - four radiographic images |
234 |
226 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
243 |
234 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
71 |
39 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
213 |
208 |
$4K |
| D1206 |
Topical application of fluoride varnish |
81 |
80 |
$1K |
| D1120 |
Prophylaxis - child |
47 |
46 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
26 |
13 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
64 |
60 |
$512.00 |