| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
350 |
345 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
412 |
404 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
153 |
96 |
$10K |
| D0274 |
Bitewings - four radiographic images |
182 |
182 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
50 |
40 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
162 |
155 |
$3K |
| D1120 |
Prophylaxis - child |
79 |
74 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
48 |
44 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
18 |
15 |
$1K |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$448.81 |
| D0220 |
Intraoral - periapical first radiographic image |
30 |
30 |
$270.04 |