| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
200 |
199 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
307 |
306 |
$6K |
| D0330 |
Panoramic radiographic image |
65 |
64 |
$2K |
| D0274 |
Bitewings - four radiographic images |
79 |
79 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
32 |
25 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
34 |
25 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
129 |
126 |
$970.15 |
| D1208 |
Topical application of fluoride, excluding varnish |
33 |
33 |
$625.60 |
| D0272 |
Bitewings - two radiographic images |
35 |
34 |
$569.80 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$335.40 |