| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
574 |
558 |
$24K |
| D0274 |
Bitewings - four radiographic images |
407 |
400 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
125 |
45 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
239 |
234 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
297 |
290 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
72 |
38 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
28 |
27 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
56 |
54 |
$1K |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$750.61 |