| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
412 |
388 |
$31K |
| D0330 |
Panoramic radiographic image |
244 |
217 |
$21K |
| D0274 |
Bitewings - four radiographic images |
333 |
301 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
257 |
231 |
$15K |
| D1206 |
Topical application of fluoride varnish |
200 |
179 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
16 |
12 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
68 |
65 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
26 |
25 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$651.50 |