| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
605 |
589 |
$15K |
| D0330 |
Panoramic radiographic image |
180 |
176 |
$14K |
| D1110 |
Prophylaxis - adult |
255 |
246 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
111 |
90 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
296 |
289 |
$7K |
| D1120 |
Prophylaxis - child |
211 |
207 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
94 |
92 |
$5K |
| D0272 |
Bitewings - two radiographic images |
17 |
14 |
$334.05 |