| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
873 |
855 |
$27K |
| D0120 |
Periodic oral evaluation - established patient |
1,116 |
1,092 |
$18K |
| D0330 |
Panoramic radiographic image |
169 |
162 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
432 |
422 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
63 |
43 |
$3K |
| D1120 |
Prophylaxis - child |
127 |
127 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
51 |
30 |
$2K |
| D0274 |
Bitewings - four radiographic images |
57 |
56 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
42 |
42 |
$1K |
| D0272 |
Bitewings - two radiographic images |
33 |
32 |
$0.00 |