| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,210 |
1,031 |
$44K |
| D0120 |
Periodic oral evaluation - established patient |
998 |
863 |
$17K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
291 |
169 |
$17K |
| D0330 |
Panoramic radiographic image |
256 |
185 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
224 |
118 |
$11K |
| D0274 |
Bitewings - four radiographic images |
278 |
228 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
233 |
170 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
253 |
224 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
36 |
27 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
57 |
48 |
$653.38 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$414.00 |