| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
183 |
173 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
250 |
246 |
$4K |
| D0274 |
Bitewings - four radiographic images |
140 |
132 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
42 |
26 |
$2K |
| D0330 |
Panoramic radiographic image |
57 |
54 |
$2K |
| D1120 |
Prophylaxis - child |
51 |
51 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
38 |
38 |
$522.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
17 |
16 |
$409.50 |