| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
419 |
415 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
323 |
321 |
$8K |
| D1330 |
|
677 |
673 |
$5K |
| D0330 |
Panoramic radiographic image |
274 |
272 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
116 |
54 |
$3K |
| D1110 |
Prophylaxis - adult |
573 |
569 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
30 |
24 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
198 |
198 |
$1K |
| D0274 |
Bitewings - four radiographic images |
227 |
226 |
$215.73 |
| D0431 |
|
125 |
123 |
$92.40 |