| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
243 |
242 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
120 |
119 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
262 |
260 |
$6K |
| D0330 |
Panoramic radiographic image |
92 |
91 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
24 |
14 |
$4K |
| D0274 |
Bitewings - four radiographic images |
130 |
129 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
12 |
12 |
$381.72 |
| D0220 |
Intraoral - periapical first radiographic image |
13 |
13 |
$128.05 |