| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,200 |
2,199 |
$118K |
| D0120 |
Periodic oral evaluation - established patient |
2,322 |
2,322 |
$66K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
357 |
233 |
$27K |
| D0274 |
Bitewings - four radiographic images |
475 |
475 |
$14K |
| D1120 |
Prophylaxis - child |
248 |
248 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
232 |
232 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
128 |
82 |
$7K |
| D0330 |
Panoramic radiographic image |
169 |
169 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
201 |
201 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
56 |
56 |
$556.00 |